=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801430657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELE FRANCINE OMADJELA PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2019
-----------------------------------------------------
Last Update Date | 12/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14524 POTOMAC MILLS RD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-6803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-490-6726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17293 WEXFORD LOOP
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22026-3333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-494-7558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305213283
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------