Healthcare Provider Details

I. General information

NPI: 1407012859
Provider Name (Legal Business Name): ATOOSA DEYANAT PURVEYOR DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ATOOSA DEYANAT-YAZDI

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SENTARA CIR RM 2C
WILLIAMSBURG VA
23188-5713
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-984-7217
  • Fax: 757-984-7210
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024167928
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: