Provider Demographics
NPI:1154316511
Name:SIMONETTI, GINA M (DC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 OLD LEE HWY
Mailing Address - Street 2:22C
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2432
Mailing Address - Country:US
Mailing Address - Phone:703-385-7007
Mailing Address - Fax:703-385-4384
Practice Address - Street 1:3915 OLD LEE HWY
Practice Address - Street 2:22C
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2432
Practice Address - Country:US
Practice Address - Phone:703-385-7007
Practice Address - Fax:703-385-4384
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000926111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0817136OtherAETNA
VA070511OtherANTHEM
U20831Medicare UPIN
000D02P77Medicare ID - Type Unspecified