Provider Demographics
NPI:1538369848
Name:SELASSIE, LEELIE M
Entity type:Individual
Prefix:
First Name:LEELIE
Middle Name:M
Last Name:SELASSIE
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:INOVA FAIRFAX HOSPITAL/ PHYSICIAN BILLING
Mailing Address - Street 2:3300 GALLOWS ROAD
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3300
Mailing Address - Country:US
Mailing Address - Phone:703-776-2545
Mailing Address - Fax:703-776-2917
Practice Address - Street 1:INOVA FAIRFAX HOSPITAL/ PHYSICIAN BILLING
Practice Address - Street 2:3300 GALLOWS ROAD
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3300
Practice Address - Country:US
Practice Address - Phone:703-776-2545
Practice Address - Fax:703-776-2917
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236721207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine