Provider Demographics
NPI:1164143871
Name:MUDIDA, ROSE
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:MUDIDA
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 1:4400 W BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1010
Mailing Address - Country:US
Mailing Address - Phone:703-379-6000
Mailing Address - Fax:703-671-8897
Practice Address - Street 1:4400 W BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1099
Practice Address - Country:US
Practice Address - Phone:703-379-6000
Practice Address - Fax:703-671-8897
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1871376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator