Healthcare Provider Details

I. General information

NPI: 1649586934
Provider Name (Legal Business Name): JESSICA MARY CORTEZZO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY
RESTON VA
20190-3219
US

IV. Provider business mailing address

1122 BASIL RD
MC LEAN VA
22101-1802
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-9000
  • Fax:
Mailing address:
  • Phone: 310-922-7097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024169038
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: