Healthcare Provider Details

I. General information

NPI: 1215996277
Provider Name (Legal Business Name): LISA DAWN REYNOLDS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MISS LISA DAWN GREGOIRE

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 MAPLE AVE WEST STE 5
VIENNA VA
22180
US

IV. Provider business mailing address

10400 EATON PLACE STE 410
FAIRFAX VA
22030
US

V. Phone/Fax

Practice location:
  • Phone: 703-938-2244
  • Fax: 703-938-3669
Mailing address:
  • Phone: 703-359-5160
  • Fax: 703-383-9574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024164882
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: