Provider Demographics
NPI:1679099196
Name:ALI, MARIUM LAIQ (DNP)
Entity type:Individual
Prefix:DR
First Name:MARIUM
Middle Name:LAIQ
Last Name:ALI
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:MARIUM
Other - Middle Name:
Other - Last Name:LAIQ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10858 SANTA CLARA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4463
Mailing Address - Country:US
Mailing Address - Phone:571-594-0741
Mailing Address - Fax:
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3311
Practice Address - Country:US
Practice Address - Phone:703-523-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175227367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered