Healthcare Provider Details

I. General information

NPI: 1295671469
Provider Name (Legal Business Name): MAYERLINE EULALIA FANAS MA RIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8171 HONEY BEE WAY APT 101
MANASSAS VA
20111-7210
US

IV. Provider business mailing address

8171 HONEY BEE WAY APT 101
MANASSAS VA
20111-7210
US

V. Phone/Fax

Practice location:
  • Phone: 917-566-2578
  • Fax:
Mailing address:
  • Phone: 917-566-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0704016834
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: