Healthcare Provider Details

I. General information

NPI: 1245704766
Provider Name (Legal Business Name): MONIQUE CHINYERE NWALA MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 ELDEN ST STE 300
HERNDON VA
20170-5572
US

IV. Provider business mailing address

703 ANDOVER CT
CHESAPEAKE VA
23322-7387
US

V. Phone/Fax

Practice location:
  • Phone: 703-840-4705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: