Healthcare Provider Details

I. General information

NPI: 1346716503
Provider Name (Legal Business Name): MARY KIMMEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CENTREVILLE RD
HERNDON VA
20171-3639
US

IV. Provider business mailing address

13616 BRITISH MANOR CT
CENTREVILLE VA
20120-1782
US

V. Phone/Fax

Practice location:
  • Phone: 814-444-2381
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202219673
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP452896
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: