Healthcare Provider Details

I. General information

NPI: 1124762968
Provider Name (Legal Business Name): LUMIERE TUFUKA BAKATUBALA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 OPITZ BLVD STE A
WOODBRIDGE VA
22191-3332
US

IV. Provider business mailing address

2026 OPITZ BLVD STE A
WOODBRIDGE VA
22191-3332
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-7155
  • Fax:
Mailing address:
  • Phone: 703-491-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0024183787
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: