Healthcare Provider Details

I. General information

NPI: 1326017146
Provider Name (Legal Business Name): CAROLYN SHEREDY RN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 OLD BRIDGE RD STE 101 ALEXANDRIA LAKE RIDGE PEDIATRICS
WOODBRIDGE VA
22192-2383
US

IV. Provider business mailing address

1500 N BEAUREGARD ST SUITE 200
ALEXANDRIA VA
22311-1723
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-4131
  • Fax: 703-499-9670
Mailing address:
  • Phone: 703-212-6600
  • Fax: 703-931-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberPNP0024069761
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: