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General NPI Number Information
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NPI Number | 1023896586
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Entity Type | Organization
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Legal Business Name | PHOENIXMIDES LLC
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Dates
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Enumeration Date | 09/18/2023
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 591 OAKWOOD CIR
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City | PETERSBURG
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State | VA
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Zip | 23805-9339
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Country | US
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Telephone | 540-204-2459
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Fax |
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Provider Business Mailing Address
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Address Line | 5706 GOSSAMER CT
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City | MOSELEY
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State | VA
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Zip | 23120-2339
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Country | US
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Telephone | 154-020-4245
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Fax |
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Authorized Official
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Title or Position | PSYCHIATRIC NURSE PRACTITIONER
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Name | OLUWASEYI OLADIPUPO SOETAN
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Credential | PMHNP-BC
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Telephone | 540-204-2459
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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