Healthcare Provider Details

I. General information

NPI: 1407854250
Provider Name (Legal Business Name): MARIA LUCILLE FAIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LUCILLE QUIZON FAIN CRNA

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JOSEPH SIEWICK DR
FAIRFAX VA
22033-1709
US

IV. Provider business mailing address

11781 LEE JACKSON MEMORIAL HWY
FAIRFAX VA
22033-3309
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-3129
  • Fax:
Mailing address:
  • Phone: 571-777-5164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0021467208
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN67020
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: