Healthcare Provider Details

I. General information

NPI: 1629607882
Provider Name (Legal Business Name): MELANIE HERRIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6230 ROLLING RD STE J
SPRINGFIELD VA
22152-2326
US

IV. Provider business mailing address

315 WILKES ST
ALEXANDRIA VA
22314-3719
US

V. Phone/Fax

Practice location:
  • Phone: 571-665-6460
  • Fax: 571-565-6561
Mailing address:
  • Phone: 703-307-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024179126
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024179126
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: