Provider Demographics
NPI:1639406317
Name:KNUDSEN, COLETTE T (RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:T
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 RICHMOND HWY STE 301
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-2344
Mailing Address - Country:US
Mailing Address - Phone:703-704-7082
Mailing Address - Fax:703-704-6679
Practice Address - Street 1:8350 RICHMOND HWY STE 301
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-2344
Practice Address - Country:US
Practice Address - Phone:703-704-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173673363L00000X
VA0001098727163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639406317Medicaid
WIMK2096471OtherDEA