=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982420493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA DIABETES PREVENTION & MANAGEMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2024
-----------------------------------------------------
Last Update Date | 05/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12311 BEECHNUT CT
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-586-3751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12311 BEECHNUT CT
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-586-2751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LIFESTYLE COACH/DSMES
-----------------------------------------------------
Name | CHARITY C NWANEVU
-----------------------------------------------------
Credential | RN-MPH
-----------------------------------------------------
Telephone | 703-586-2751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------