Healthcare Provider Details

I. General information

NPI: 1780144865
Provider Name (Legal Business Name): DR. ELIZABETH CHINKE ICHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955E WONDER RD
STAFFORD VA
22554-7798
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD STE 100
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-7893
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101288349
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021-00823
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: