Provider Demographics
NPI:1265852032
Name:FOSSUM, BRANDI RENEE (ACNPC-AG, RNFA, CNOR)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:RENEE
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:ACNPC-AG, RNFA, CNOR
Other - Prefix:MS
Other - First Name:BRANDI
Other - Middle Name:RENEE
Other - Last Name:BURROWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14605 POTOMAC BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3336
Mailing Address - Country:US
Mailing Address - Phone:703-490-1112
Mailing Address - Fax:703-878-8735
Practice Address - Street 1:14605 POTOMAC BRANCH DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3336
Practice Address - Country:US
Practice Address - Phone:703-490-1112
Practice Address - Fax:703-878-8735
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001219358163W00000X, 163WR0006X
VA0024178671363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant