Healthcare Provider Details

I. General information

NPI: 1063074896
Provider Name (Legal Business Name): MISS GINA MARIE PORCELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9833 PATRIOT HWY
FREDERICKSBURG VA
22407-9422
US

IV. Provider business mailing address

10520 ABBERLY VILLAGE LN APT 123
FREDERICKSBURG VA
22407-2728
US

V. Phone/Fax

Practice location:
  • Phone: 540-847-1936
  • Fax:
Mailing address:
  • Phone: 540-604-7528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133003729
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: