Provider Demographics
NPI:1265146229
Name:MACAULLY, KHADIJA
Entity type:Individual
Prefix:
First Name:KHADIJA
Middle Name:
Last Name:MACAULLY
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 1:202 MARIANNE PL
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1621
Mailing Address - Country:US
Mailing Address - Phone:571-275-0132
Mailing Address - Fax:
Practice Address - Street 1:12018 SUNRISE VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3444
Practice Address - Country:US
Practice Address - Phone:571-262-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily