Provider Demographics
NPI:1215522297
Name:MARYMOUNT UNIVERSITY
Entity type:Organization
Organization Name:MARYMOUNT UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:703-284-1610
Mailing Address - Street 1:2807 N GLEBE RD
Mailing Address - Street 2:BERG HALL 1014
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-4299
Mailing Address - Country:US
Mailing Address - Phone:703-284-1610
Mailing Address - Fax:703-284-3816
Practice Address - Street 1:2807 N GLEBE RD
Practice Address - Street 2:BERG HALL 1014
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-4299
Practice Address - Country:US
Practice Address - Phone:703-284-1610
Practice Address - Fax:703-284-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty