Healthcare Provider Details

I. General information

NPI: 1891460549
Provider Name (Legal Business Name): JUDITH TALLANT BAGGETT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2021
Last Update Date: 01/10/2024
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 OLD MEADOW RD STE 500
MC LEAN VA
22102-4306
US

IV. Provider business mailing address

1760 OLD MEADOW RD STE 500
MC LEAN VA
22102-4306
US

V. Phone/Fax

Practice location:
  • Phone: 703-810-5217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0024182365
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024182365
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: