Healthcare Provider Details

I. General information

NPI: 1083611107
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA/STATE BOARD OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1303
US

IV. Provider business mailing address

416 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1927
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-7305
  • Fax: 757-594-7714
Mailing address:
  • Phone: 757-594-7305
  • Fax: 757-594-7714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number00240339042
License Number StateVA

VIII. Authorized Official

Name: DR. NATASHA DWAMENA
Title or Position: HEALTH DIRECTOR
Credential: MD
Phone: 757-594-7300