Provider Demographics
NPI:1619657350
Name:DIVITO, ANNALISA
Entity type:Individual
Prefix:
First Name:ANNALISA
Middle Name:
Last Name:DIVITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2451
Mailing Address - Country:US
Mailing Address - Phone:781-974-9171
Mailing Address - Fax:
Practice Address - Street 1:14801 DINING WAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4075
Practice Address - Country:US
Practice Address - Phone:703-763-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist