Provider Demographics
NPI:1336297050
Name:MONDESIR-INNOCENT, NATHALIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHALIE
Middle Name:
Last Name:MONDESIR-INNOCENT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 COVER LN
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3414
Mailing Address - Country:US
Mailing Address - Phone:301-283-2387
Mailing Address - Fax:703-805-0522
Practice Address - Street 1:9501 FARRELL RD STE OC11
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:703-805-9089
Practice Address - Fax:703-805-0522
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002938363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical