MEDICARE: DR. MARY KATHLEEN HUMPHRIES D.O.

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	207Q00000X	Family Medicine Physician	0102206943	VA

General Provider Information

NPI Number	:	1578862173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KATHLEEN HUMPHRIES D.O.

Provider Business Mailing Address
First Line	:	1200 N QUAKER LN
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-3004
Country	:	US
Telephone Number	:	47-807-6022
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 N QUAKER LN
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22302-3004
Country	:	US
Telephone Number	:	47-807-6022
Fax Number	:

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

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/27/2025

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