Healthcare Provider Details

I. General information

NPI: 1093051237
Provider Name (Legal Business Name): AEDEN GHEBRESELASSIE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 CAPITAL ONE DR
MC LEAN VA
22102-3407
US

IV. Provider business mailing address

1680 CAPITAL ONE DR
MC LEAN VA
22102-3407
US

V. Phone/Fax

Practice location:
  • Phone: 703-720-1290
  • Fax: 703-720-1291
Mailing address:
  • Phone: 703-720-1291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174118
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: