1053692343 NPI number — TRACI ANNETTA MARIN CNM

Table of content: TRACI ANNETTA MARIN CNM (NPI 1053692343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053692343 NPI number — TRACI ANNETTA MARIN CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARIN
Provider First Name:
TRACI
Provider Middle Name:
ANNETTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053692343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14701 ROUTE 29 STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTREVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20121-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14701 LEE HWY
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
CENTREVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20121-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-830-4388
Provider Business Practice Location Address Fax Number:
703-830-4188
Provider Enumeration Date:
08/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  0024169463 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30016037770003 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053692343 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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