Healthcare Provider Details

I. General information

NPI: 1790401602
Provider Name (Legal Business Name): LATASHA NYE BROCKINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6312 SEVEN CORNERS CTR # 386
FALLS CHURCH VA
22044-2409
US

IV. Provider business mailing address

7000 S KENFIG DR
FALLS CHURCH VA
22042-3866
US

V. Phone/Fax

Practice location:
  • Phone: 202-643-5571
  • Fax:
Mailing address:
  • Phone: 843-834-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0129000222
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: