Healthcare Provider Details

I. General information

NPI: 1659377612
Provider Name (Legal Business Name): MIRIAM S NEW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SENTARA CIRCLE SUITE 203
WILLIAMSBURG VA
23188-5727
US

IV. Provider business mailing address

6350 CENTER DR SUITE 200
NORFOLK VA
23502
US

V. Phone/Fax

Practice location:
  • Phone: 757-873-9400
  • Fax: 757-213-5701
Mailing address:
  • Phone: 757-213-5700
  • Fax: 757-213-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024164788
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: