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General NPI Number Information
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NPI Number | 1245053966
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Entity Type | Individual
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Provider Name | EVELYN BUTSOME SALLAH-KOOMSON APRN FNP-C
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Gender |
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Dates
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Enumeration Date | 11/01/2024
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 106 ELDEN ST STE 18B
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City | HERNDON
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State | VA
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Zip | 20170-4826
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Country | US
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Telephone | 703-723-9100
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Fax | 703-723-9200
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Provider Business Mailing Address
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Address Line | 106 ELDEN ST STE 18B
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City | HERNDON
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State | VA
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Zip | 20170-4826
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Country | US
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Telephone | 703-723-9100
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Fax | 703-723-9200
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0024191662
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License Number State | VA
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