Healthcare Provider Details

I. General information

NPI: 1235927047
Provider Name (Legal Business Name): CHIAZAM GRACE OMENYI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 06/29/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

5001 ELLIS LN
ELLICOTT CITY MD
21043-6866
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116041007
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: