=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275798878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY STRUBE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2008
-----------------------------------------------------
Last Update Date | 05/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7901 LAKE MANASSAS DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-222-2200
-----------------------------------------------------
Fax | 703-361-5561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7901 LAKE MANASSAS DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-222-2200
-----------------------------------------------------
Fax | 703-361-5561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024167867
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------