Healthcare Provider Details

I. General information

NPI: 1043931694
Provider Name (Legal Business Name): AGEA CHALLA TEMESGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9715 LIBERIA AVE
MANASSAS VA
20110-5837
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 571-229-1797
  • Fax:
Mailing address:
  • Phone: 804-822-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024184934
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: