1992724413 NPI number — ELETHIA V WAMPLER

Table of content: ELETHIA V WAMPLER (NPI 1992724413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992724413 NPI number — ELETHIA V WAMPLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAMPLER
Provider First Name:
ELETHIA
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1992724413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9455 LORTON MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22079-1963
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:
12825 MINNIEVILLE ROAD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-0045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-971-3701
Provider Business Practice Location Address Fax Number:
301-856-0964
Provider Enumeration Date:
07/18/2006

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: 225100000X , with the licence number:  2305002121 , 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: 46950017 . This is a "CAREFIRST NCA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64468701 . This is a "CAREFIRST MARYLAND" identifier . This identifiers is of the category "OTHER".




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