=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326408642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN VIRGINIA FOOT AND ANKLE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2016
-----------------------------------------------------
Last Update Date | 03/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8221 OLD COURTHOUSE RD STE 102
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-734-1311
-----------------------------------------------------
Fax | 703-734-9090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8221 OLD COURTHOUSE RD STE 102
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-734-1311
-----------------------------------------------------
Fax | 703-734-9090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | JILL DANSEY
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 571-213-1047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305203384
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------