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General NPI Number Information
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NPI Number | 1952463606
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Entity Type | Organization
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Legal Business Name | DOMINION FAMILY HEALTH, PLC
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Dates
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Enumeration Date | 12/15/2006
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Last Update Date | 03/03/2010
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Provider Practice Location Address
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Address Line | 5800 MAPLEDALE PLZ
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City | DALE CITY
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State | VA
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Zip | 22193-4535
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Country | US
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Telephone | 703-670-0067
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Fax | 703-670-0301
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Provider Business Mailing Address
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Address Line | 5800 MAPLEDALE PLZ
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City | DALE CITY
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State | VA
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Zip | 22193-4535
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Country | US
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Telephone | 703-670-0067
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Fax | 703-670-0301
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Authorized Official
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Title or Position | OWNER
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Name | LISA KIMBERLY MALLOY
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Credential | MD
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Telephone | 703-670-0067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101226862
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License Number State | VA
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