Provider Demographics
NPI:1992541890
Name:CHANTILLY WELLNESS GROUP, LLC
Entity type:Organization
Organization Name:CHANTILLY WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:620-504-2434
Mailing Address - Street 1:4200A TECHNOLOGY CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1214
Mailing Address - Country:US
Mailing Address - Phone:540-709-1737
Mailing Address - Fax:866-611-3615
Practice Address - Street 1:4200A TECHNOLOGY CT
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1214
Practice Address - Country:US
Practice Address - Phone:540-709-1737
Practice Address - Fax:866-611-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty