Healthcare Provider Details

I. General information

NPI: 1417350018
Provider Name (Legal Business Name): ELLEN IDUMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN JOHN

II. Dates (important events)

Enumeration Date: 09/27/2014
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 NEW GUINEA RD
FAIRFAX VA
22032-3268
US

IV. Provider business mailing address

9420 PARK HUNT CT
SPRINGFIELD VA
22153-1351
US

V. Phone/Fax

Practice location:
  • Phone: 703-764-5112
  • Fax:
Mailing address:
  • Phone: 703-909-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171998
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: