Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 0024173036 | VA |
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 0024173036 | VA |
NPI | 1003289729 |
---|---|
Provider Name | Carol Gavin |
First Address | Leesburg, VA 20176-4487 |
Second Address | Leesburg, VA 20176-4487 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2015 |
Last Update Date | 30/12/2021 |