Healthcare Provider Details

I. General information

NPI: 1083453492
Provider Name (Legal Business Name): LIFELONG WELLNESS & GYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 ARLINGTON BLVD STE 510
FALLS CHURCH VA
22042-2325
US

IV. Provider business mailing address

3246 KENNEY DR
FALLS CHURCH VA
22042-3629
US

V. Phone/Fax

Practice location:
  • Phone: 703-375-9525
  • Fax:
Mailing address:
  • Phone: 703-375-9525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LAUREN GEVANA OUTLAW
Title or Position: OWNER
Credential: MD
Phone: 504-905-8669