Provider Demographics
NPI:1285308528
Name:MUTISYA, MILLICENT M
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:M
Last Name:MUTISYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:703-940-8697
Practice Address - Street 1:8613 ROUTE 29 # 200N
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2171
Practice Address - Country:US
Practice Address - Phone:571-350-8400
Practice Address - Fax:703-280-9596
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180473363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2H1702OtherMEDICARE PTAN
VA1285308528Medicaid