=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083453492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELONG WELLNESS & GYNECOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2024
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6400 ARLINGTON BLVD STE 510
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22042-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-375-9525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3246 KENNEY DR
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22042-3629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-375-9525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAUREN GEVANA OUTLAW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 504-905-8669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------