Healthcare Provider Details

I. General information

NPI: 1619935061
Provider Name (Legal Business Name): ELIZABETH JANE MAIDEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR SUITE 100
NORTH CHESTERFIELD VA
23235-4730
US

IV. Provider business mailing address

7202 GLEN FOREST DR SUITE 200
RICHMOND VA
23226-3781
US

V. Phone/Fax

Practice location:
  • Phone: 804-330-7990
  • Fax: 804-330-3541
Mailing address:
  • Phone: 804-673-2024
  • Fax: 804-673-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164124
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: