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General NPI Number Information
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NPI Number | 1679089361
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Entity Type | Individual
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Provider Name | THEOPHILINE MARY EBIASAH
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Gender | Female
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Dates
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Enumeration Date | 12/18/2017
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Last Update Date | 12/18/2017
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Provider Practice Location Address
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Address Line | 10701 ROSEMARY DR
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City | MANASSAS
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State | VA
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Zip | 20109-7282
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Country | US
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Telephone | 703-257-3000
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Fax | 703-257-3057
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Provider Business Mailing Address
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Address Line | 8405 MOSSY PINES WAY
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City | GAINESVILLE
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State | VA
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Zip | 20155-5209
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Country | US
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Telephone | 703-969-4300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WL0100X
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Taxonomy Name | Lactation Consultant (Registered Nurse)
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License Number | 0001174655
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License Number State | VA
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