Healthcare Provider Details

I. General information

NPI: 1578524096
Provider Name (Legal Business Name): DIANE MARY CONNESS-JABLONSKI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE M. CONNESS O.D.

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12444 DILLINGHAM SQ
WOODBRIDGE VA
22192-5258
US

IV. Provider business mailing address

12444 DILLINGHAM SQ
WOODBRIDGE VA
22192-5258
US

V. Phone/Fax

Practice location:
  • Phone: 703-680-4323
  • Fax: 703-680-4358
Mailing address:
  • Phone: 703-680-4323
  • Fax: 703-680-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: