Healthcare Provider Details

I. General information

NPI: 1093096281
Provider Name (Legal Business Name): COMMUNITY CARE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9444 TANEY RD 103
MANASSAS VA
20110-5933
US

IV. Provider business mailing address

9430 FORESTWOOD LN 100
MANASSAS VA
20110-4753
US

V. Phone/Fax

Practice location:
  • Phone: 703-365-0227
  • Fax: 703-365-0332
Mailing address:
  • Phone: 703-365-0227
  • Fax: 703-365-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024166627
License Number StateVA

VIII. Authorized Official

Name: MRS. JENNIFER MICHELLE SCHMIDT
Title or Position: PRACTITIONER
Credential: CFNP
Phone: 703-365-0227