Healthcare Provider Details

I. General information

NPI: 1043914245
Provider Name (Legal Business Name): AMEN C OTUNBA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 RICHMOND HWY
LORTON VA
22079-2124
US

IV. Provider business mailing address

3360 POST OFFICE RD UNIT 1796
WOODBRIDGE VA
22195-8052
US

V. Phone/Fax

Practice location:
  • Phone: 571-800-8915
  • Fax: 833-954-5512
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024186850
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: