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General NPI Number Information
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NPI Number | 1417658980
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Entity Type | Organization
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Legal Business Name | BLUE MANTLE MEDICINE PLLC
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Dates
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Enumeration Date | 03/13/2023
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 4001 FAIR RIDGE DR STE 305
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City | FAIRFAX
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State | VA
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Zip | 22033-2917
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Country | US
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Telephone | 540-701-4767
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Fax | 703-520-9880
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Provider Business Mailing Address
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Address Line | 4001 FAIR RIDGE DR STE 305
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City | FAIRFAX
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State | VA
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Zip | 22033-2917
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Country | US
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Telephone | 540-701-4767
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Fax | 703-520-9880
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Authorized Official
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Title or Position | MD
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Name | SITA CANADY
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Credential |
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Telephone | 540-645-1856
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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