Healthcare Provider Details

I. General information

NPI: 1306883418
Provider Name (Legal Business Name): BRENDA RAE CRUM CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA R PETERMAN CFNP

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 OPITZ BLVD STE 110
WOODBRIDGE VA
22191-3362
US

IV. Provider business mailing address

2280 OPITZ BLVD STE 110
WOODBRIDGE VA
22191-3362
US

V. Phone/Fax

Practice location:
  • Phone: 703-523-8880
  • Fax: 757-648-1954
Mailing address:
  • Phone: 703-523-8880
  • Fax: 757-648-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number24131318
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024131318
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: