Healthcare Provider Details

I. General information

NPI: 1336618263
Provider Name (Legal Business Name): MINERVA HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CEDARFIELD PKWY
RICHMOND VA
23233-1936
US

IV. Provider business mailing address

PO BOX 2516
MIDLOTHIAN VA
23113-8516
US

V. Phone/Fax

Practice location:
  • Phone: 804-464-8412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NAOMI AYLESWORTH
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 804-464-8412