Healthcare Provider Details

I. General information

NPI: 1962863233
Provider Name (Legal Business Name): IFESINACHI ANOSIKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BALCH DR S
LEESBURG VA
20175-4701
US

IV. Provider business mailing address

1607 VILLAGE MARKET BLVD SE APT 210
LEESBURG VA
20175-5109
US

V. Phone/Fax

Practice location:
  • Phone: 917-459-1158
  • Fax:
Mailing address:
  • Phone: 917-459-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024173481
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: