Provider Demographics
NPI:1245053966
Name:SALLAH-KOOMSON, EVELYN BUTSOME (APRN FNP-C)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:BUTSOME
Last Name:SALLAH-KOOMSON
Suffix:
Gender:U
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:106 ELDEN ST STE 18B
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4826
Mailing Address - Country:US
Mailing Address - Phone:703-723-9100
Mailing Address - Fax:703-723-9200
Practice Address - Street 1:106 ELDEN ST STE 18B
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4826
Practice Address - Country:US
Practice Address - Phone:703-723-9100
Practice Address - Fax:703-723-9200
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024191662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty