Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 0001161902 | VA |
NPI | 1003942921 |
---|---|
Provider Name | Ms. Martina M Lavrisha |
First Address | Rockville, MD 20852-4908 |
Second Address | Burke, VA 22015-2880 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2007 |
Last Update Date | 08/07/2007 |