Provider Demographics
NPI:1720038862
Name:MARES, KATHLEEN ELIZABETH (CANP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:MARES
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7764 ARMISTEAD RD STE 240
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1920
Mailing Address - Country:US
Mailing Address - Phone:571-359-4000
Mailing Address - Fax:703-621-3793
Practice Address - Street 1:8109 HINSON FARM RD STE 504
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3411
Practice Address - Country:US
Practice Address - Phone:703-780-2800
Practice Address - Fax:703-780-0461
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024062894363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018OtherBCBS-DC
5374OtherBCBS
1720038862OtherBCBS-VA
8304870OtherEVERCARE
P00472516Medicare PIN
0018OtherBCBS-DC
1720038862OtherBCBS-VA