1316241854 NPI number — MS. DOREEN FAYE GRZELAK NP-C

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 1316241854 NPI number — MS. DOREEN FAYE GRZELAK NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRZELAK
Provider First Name:
DOREEN
Provider Middle Name:
FAYE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAFFINCH
Provider Other First Name:
DOREEN
Provider Other Middle Name:
FAYE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316241854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3040 WILLIAMS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-350-8400
Provider Business Mailing Address Fax Number:
703-940-8697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44035 RIVERSIDE PKWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-8260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-554-6800
Provider Business Practice Location Address Fax Number:
703-724-7503
Provider Enumeration Date:
12/24/2010

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: 363LA2200X , with the licence number:  0024168894 , 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: 489421ZAN3 . This is a "MEDICARE PTAN" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1316241854 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: VVY852A . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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