Healthcare Provider Details

I. General information

NPI: 1154614048
Provider Name (Legal Business Name): SUSAN G MAGENHEIMER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVENUE, SUITE 204
LEESBURG VA
20176-8102
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-1500
  • Fax: 703-858-5022
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN1022120
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0024165070
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: