Healthcare Provider Details

I. General information

NPI: 1255504908
Provider Name (Legal Business Name): JAMIE SLAGLE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE TIPPENS

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 STERLING RD STE 203
HERNDON VA
20170-3873
US

IV. Provider business mailing address

5400 CHESHIRE MEADOWS WAY
FAIRFAX VA
22032-3216
US

V. Phone/Fax

Practice location:
  • Phone: 703-466-5150
  • Fax: 703-649-3599
Mailing address:
  • Phone: 505-967-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024171415
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024171415
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: