Healthcare Provider Details

I. General information

NPI: 1699262691
Provider Name (Legal Business Name): CRYSTAL ICENHOUR PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45925 HORSESHOE DR STE 170
STERLING VA
20166-6609
US

IV. Provider business mailing address

45925 HORSESHOE DR STE 170
STERLING VA
20166-6609
US

V. Phone/Fax

Practice location:
  • Phone: 703-229-0406
  • Fax:
Mailing address:
  • Phone: 703-229-0406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License NumberCLF0001793
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: