Healthcare Provider Details

I. General information

NPI: 1811446339
Provider Name (Legal Business Name): GIGI KHONYONGWA-FERNANDEZ OTR/L, ACC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8070 CRIANZA PL APT 471
VIENNA VA
22182-4073
US

IV. Provider business mailing address

8070 CRIANZA PL APT 471
VIENNA VA
22182-4073
US

V. Phone/Fax

Practice location:
  • Phone: 205-453-4865
  • Fax:
Mailing address:
  • Phone: 205-453-4865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119007086
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: