Provider Demographics
NPI:1497133185
Name:VAN FOSSAN, GRETCHEN (LAC, MAC)
Entity type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:
Last Name:VAN FOSSAN
Suffix:
Gender:F
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 19TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1007
Mailing Address - Country:US
Mailing Address - Phone:202-413-3342
Mailing Address - Fax:
Practice Address - Street 1:804 PERSHING DR STE 5
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4436
Practice Address - Country:US
Practice Address - Phone:202-413-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist