Healthcare Provider Details

I. General information

NPI: 1518696509
Provider Name (Legal Business Name): QUANEISHA GILLIAM LRIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS QUANEISHA ROCHELLE

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 SUNRISE VALLEY DR STE 100
RESTON VA
20191-3429
US

IV. Provider business mailing address

847 CARIBE PL
VIRGINIA BEACH VA
23462-1175
US

V. Phone/Fax

Practice location:
  • Phone: 757-754-5852
  • Fax: 757-754-5852
Mailing address:
  • Phone: 757-754-5852
  • Fax: 757-754-5852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701016125
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: