Provider Demographics
NPI:1639201643
Name:WISTHOFF, MARY CLARE (LAC, RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CLARE
Last Name:WISTHOFF
Suffix:
Gender:F
Credentials:LAC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-2645
Mailing Address - Country:US
Mailing Address - Phone:703-528-2641
Mailing Address - Fax:
Practice Address - Street 1:8830 CAMERON CT
Practice Address - Street 2:SUITE 501
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4114
Practice Address - Country:US
Practice Address - Phone:301-565-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001096201163W00000X
MDU00346171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered171100000XOther Service ProvidersAcupuncturist