=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881143378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAN A OPOKU-OTENG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2016
-----------------------------------------------------
Last Update Date | 09/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15721 TASSLEFORD LANE 101
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-723-7184
-----------------------------------------------------
Fax | 571-285-2235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15721 TASSLEFORD LN 101
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-6210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-723-7184
-----------------------------------------------------
Fax | 571-285-2235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | 464041365
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------