Provider Demographics
NPI:1457004509
Name:LANDFORD, FATMATA
Entity Type:Individual
Prefix:
First Name:FATMATA
Middle Name:
Last Name:LANDFORD
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 1:15170 BRAZIL CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5547
Mailing Address - Country:US
Mailing Address - Phone:703-300-8166
Mailing Address - Fax:
Practice Address - Street 1:15170 BRAZIL CIR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-5547
Practice Address - Country:US
Practice Address - Phone:703-300-8167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-22693251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAHCO-22683OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH