Healthcare Provider Details

I. General information

NPI: 1053303651
Provider Name (Legal Business Name): KATIE LYNNE KOTOPOULOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 03/26/2022
Certification Date: 03/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1803
  • Fax:
Mailing address:
  • Phone: 571-231-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN963008
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24166243
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: