Provider Demographics
NPI:1669158895
Name:FYNN, IDDRISA
Entity type:Individual
Prefix:MR
First Name:IDDRISA
Middle Name:
Last Name:FYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IDDRISA
Other - Middle Name:
Other - Last Name:FYNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16719 CHOWNING CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4606
Mailing Address - Country:US
Mailing Address - Phone:703-786-8941
Mailing Address - Fax:
Practice Address - Street 1:16719 CHOWNING CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4606
Practice Address - Country:US
Practice Address - Phone:170-378-6894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10961131-2023171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor