Healthcare Provider Details

I. General information

NPI: 1023582665
Provider Name (Legal Business Name): VANESSA WANSEL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11415 ISAAC NEWTON SQ S
RESTON VA
20190-5005
US

IV. Provider business mailing address

11415 ISAAC NEWTON SQ S
RESTON VA
20190-5005
US

V. Phone/Fax

Practice location:
  • Phone: 301-535-8457
  • Fax:
Mailing address:
  • Phone: 571-489-4597
  • Fax: 571-489-4597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024177558
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR154907
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: