Healthcare Provider Details

I. General information

NPI: 1174928238
Provider Name (Legal Business Name): MAURA ANN CONSTANCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10304 EATON PL STE 100
FAIRFAX VA
22030-2221
US

IV. Provider business mailing address

203 S LEE ST
FALLS CHURCH VA
22046-3925
US

V. Phone/Fax

Practice location:
  • Phone: 571-463-8620
  • Fax: 571-999-7549
Mailing address:
  • Phone: 703-508-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024164954
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164954
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: