Provider Demographics
NPI:1265059760
Name:BANI AHMAD, ELAHEH
Entity type:Individual
Prefix:
First Name:ELAHEH
Middle Name:
Last Name:BANI AHMAD
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 1:8425 HAMPTON FARMS DR
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-1713
Mailing Address - Country:US
Mailing Address - Phone:180-493-3287
Mailing Address - Fax:
Practice Address - Street 1:8425 HAMPTON FARMS DR
Practice Address - Street 2:
Practice Address - City:MOSELEY
Practice Address - State:VA
Practice Address - Zip Code:23120-1713
Practice Address - Country:US
Practice Address - Phone:180-493-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179498363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner