Provider Demographics
NPI:1508600362
Name:IGHEDO, AMAZING-GRACE
Entity type:Individual
Prefix:MRS
First Name:AMAZING-GRACE
Middle Name:
Last Name:IGHEDO
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 1:23632 SAILFISH SQ
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-7633
Mailing Address - Country:US
Mailing Address - Phone:515-305-6365
Mailing Address - Fax:
Practice Address - Street 1:RESTON HOSPITAL CENTER
Practice Address - Street 2:607 HERNDON PARKWAY SUITE 101
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20171
Practice Address - Country:US
Practice Address - Phone:703-471-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001309826163W00000X
VA0024190753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse