Healthcare Provider Details

I. General information

NPI: 1902644073
Provider Name (Legal Business Name): WENDY KOKUI ACOLATSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12006 KILARNEY DR
FREDERICKSBURG VA
22407-7207
US

IV. Provider business mailing address

2300 FALL HILL AVE STE 317
FREDERICKSBURG VA
22401-3343
US

V. Phone/Fax

Practice location:
  • Phone: 540-786-9771
  • Fax:
Mailing address:
  • Phone: 540-741-1041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024189462
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: