Healthcare Provider Details

I. General information

NPI: 1336297050
Provider Name (Legal Business Name): NATHALIE MONDESIR-INNOCENT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 FARRELL RD STE OC11
FORT BELVOIR VA
22060-5901
US

IV. Provider business mailing address

607 COVER LN
ACCOKEEK MD
20607-3414
US

V. Phone/Fax

Practice location:
  • Phone: 703-805-9089
  • Fax: 703-805-0522
Mailing address:
  • Phone: 301-283-2387
  • Fax: 703-805-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002938
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: