=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457004509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FATMATA LANDFORD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2022
-----------------------------------------------------
Last Update Date | 01/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15170 BRAZIL CIR
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-5547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-300-8167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15170 BRAZIL CIR
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-5547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-300-8166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCO-22693
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------