Healthcare Provider Details

I. General information

NPI: 1356843502
Provider Name (Legal Business Name): MRS. ANNA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2018
Last Update Date: 03/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43130 AMBERWOOD PLZ STE 140
SOUTH RIDING VA
20152-4107
US

IV. Provider business mailing address

43130 AMBERWOOD PLZ STE 140
SOUTH RIDING VA
20152-4107
US

V. Phone/Fax

Practice location:
  • Phone: 703-348-0030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024175929
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: