Healthcare Provider Details

I. General information

NPI: 1689588022
Provider Name (Legal Business Name): BENJAMIN MENNITT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2296 OPITZ BLVD STE 350
WOODBRIDGE VA
22191-3346
US

IV. Provider business mailing address

2296 OPITZ BLVD STE 350
WOODBRIDGE VA
22191-3346
US

V. Phone/Fax

Practice location:
  • Phone: 571-385-3554
  • Fax:
Mailing address:
  • Phone: 571-385-3554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: