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General NPI Number Information
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NPI Number | 1801349915
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Entity Type | Organization
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Legal Business Name | BRISTOW RUN FAMILY MEDICINE
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Dates
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Enumeration Date | 07/26/2016
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Last Update Date | 07/26/2016
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Provider Practice Location Address
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Address Line | 14540 JOHN MARSHALL HWY #104
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City | GAINESVILLE
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State | VA
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Zip | 20155-1691
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Country | US
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Telephone | 703-753-9799
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Fax |
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Provider Business Mailing Address
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Address Line | 1134 S THOMAS ST APT 1
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City | ARLINGTON
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State | VA
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Zip | 22204-3621
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Country | US
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Telephone | 919-538-1712
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | JENNIFER M STALEY
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Credential | FNP
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Telephone | 919-538-1712
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0024173774
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License Number State | VA
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