=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568284008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFULVISION PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 WHEELWRIGHT LN
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-8833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-698-4259
-----------------------------------------------------
Fax | 540-736-0264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 WHEELWRIGHT LN
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-8833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-698-4259
-----------------------------------------------------
Fax | 540-736-0264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. TEMILOLUWA O ILESANMI
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 540-698-4259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------