1295810117 NPI number — DEPARTMENT OF STATE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295810117 NPI number — DEPARTMENT OF STATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF STATE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1295810117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 FREETOWN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULLES
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20189-2160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-388-6651
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DEPARTMENT OF STATE
Provider Second Line Business Practice Location Address:
2401 E STREET NW, M/MED/QI, SA-1
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20522-0102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-663-2453
Provider Business Practice Location Address Fax Number:
202-663-3247
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIEH
Authorized Official First Name:
CLARA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
HEALTH PRACTITIONER/FNP
Authorized Official Telephone Number:
202-663-2453

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  6695 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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