Provider Demographics
NPI:1407460868
Name:ANDERSON, MELISSA SUE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2667 AVENIR PLACE
Mailing Address - Street 2:APT 3223
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:908-455-0266
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3300
Practice Address - Country:US
Practice Address - Phone:703-289-8678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR198239163W00000X
VA0024180049363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse