Provider Demographics
NPI:1598321242
Name:NUR, FADUMA
Entity Type:Individual
Prefix:
First Name:FADUMA
Middle Name:
Last Name:NUR
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 1:10686 CRESTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4407
Mailing Address - Country:US
Mailing Address - Phone:703-392-6166
Mailing Address - Fax:703-392-3885
Practice Address - Street 1:10686 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4407
Practice Address - Country:US
Practice Address - Phone:703-392-6166
Practice Address - Fax:703-392-3885
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-82676106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982676OtherREGISTERED BEHAVIOR TECHNICIAN