Healthcare Provider Details

I. General information

NPI: 1063200749
Provider Name (Legal Business Name): WAVERLY BROOKE KUNDYSEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

7252 LAKE EDGE DR
DALLAS TX
75230-2397
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-4002
  • Fax:
Mailing address:
  • Phone: 214-796-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116040500
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: