MEDICARE: EMILY LEAGUE PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024189645	VA

General Provider Information

NPI Number	:	1043077951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY LEAGUE PMHNP

Provider Business Mailing Address
First Line	:	2808 FOX CHASE LN
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4008
Country	:	US
Telephone Number	:	804-303-9622
Fax Number	:

Provider Business Practice Location Address
First Line	:	7201 GLEN FOREST DR STE 304
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-3759
Country	:	US
Telephone Number	:	804-303-9622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	05/19/2026

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