Healthcare Provider Details

I. General information

NPI: 1679496459
Provider Name (Legal Business Name): PURE PEDIATRICS & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

893B HARRISON ST SE
LEESBURG VA
20175-4519
US

IV. Provider business mailing address

893B HARRISON ST SE
LEESBURG VA
20175-4519
US

V. Phone/Fax

Practice location:
  • Phone: 571-308-2813
  • Fax: 800-305-8056
Mailing address:
  • Phone: 571-308-2813
  • Fax: 800-305-8056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATIE ANNE MACDONALD
Title or Position: DIRECTOR
Credential: CPNP-PC
Phone: 240-678-3397