Provider Demographics
NPI:1427232081
Name:SIMMONS WYLLIE, NATASHA C (MD)
Entity Type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:C
Last Name:SIMMONS WYLLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:C
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12011 LEE JACKSON MEMORIAL HIGHWAY
Mailing Address - Street 2:#504
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-391-2030
Mailing Address - Fax:703-273-3943
Practice Address - Street 1:22895 BRAMBLETON PLAZA
Practice Address - Street 2:SUITE 200
Practice Address - City:BRAMBLETON
Practice Address - State:VA
Practice Address - Zip Code:20148
Practice Address - Country:US
Practice Address - Phone:703-722-2312
Practice Address - Fax:703-722-2317
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8344207Q00000X
VA0101248112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0A5248Medicare UPIN