1184016859 NPI number — FAWN WORKMAN FNP-C, PMHNP- BC

Table of content: FAWN WORKMAN FNP-C, PMHNP- BC (NPI 1184016859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184016859 NPI number — FAWN WORKMAN FNP-C, PMHNP- BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WORKMAN
Provider First Name:
FAWN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C, PMHNP- BC
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:
1184016859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14805 FOREST RD STE 107A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24551-3997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-260-3380
Provider Business Mailing Address Fax Number:
434-302-9638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14805 FOREST RD STE 107A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24551-3997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-260-3380
Provider Business Practice Location Address Fax Number:
434-302-9638
Provider Enumeration Date:
03/04/2015

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: 363LF0000X , with the licence number:  0024172310 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 0024172310 , 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)