Provider Demographics
NPI:1831504653
Name:SMITH, TAMMY (RN MSN FNP-C)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN MSN FNP-C
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Other - First Name:
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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?:Yes
Enumeration Date:2014-07-01
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024172082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1831504653Medicaid
DC2G5043OtherMEDICARE PTAN