Healthcare Provider Details

I. General information

NPI: 1679296594
Provider Name (Legal Business Name): TARYN NICHELLE PETTIGREW OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 GENESEE PL STE 209
LAKE RIDGE VA
22192-8305
US

IV. Provider business mailing address

15061 GALAPAGOS PL
WOODBRIDGE VA
22193-5842
US

V. Phone/Fax

Practice location:
  • Phone: 703-457-8648
  • Fax:
Mailing address:
  • Phone: 703-875-1489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOC018708
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119009818
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: