=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114426392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVIYALAXMI MURUGANANDAM PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 ELDEN ST STE 1000
-----------------------------------------------------
City | HERNDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20170-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-481-1505
-----------------------------------------------------
Fax | 703-742-8793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 BOYD POINTE WAY APT 2710
-----------------------------------------------------
City | TYSONS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-7561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-981-5533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0110006077
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 0110006077
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------