Healthcare Provider Details

I. General information

NPI: 1396790945
Provider Name (Legal Business Name): ANA ANZOLA CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 OLD CHAIN BRIDGE RD STE 185
MC LEAN VA
22101-3945
US

IV. Provider business mailing address

1320 OLD CHAIN BRIDGE RD STE 185
MC LEAN VA
22101-3945
US

V. Phone/Fax

Practice location:
  • Phone: 703-942-8110
  • Fax: 301-231-5171
Mailing address:
  • Phone: 703-942-8110
  • Fax: 703-942-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2101001335
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number00764
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number00764
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201000598
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: