Provider Demographics
NPI:1891340055
Name:NINAS HEALTH CARE FAIRFAX INCORPORATED
Entity type:Organization
Organization Name:NINAS HEALTH CARE FAIRFAX INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONGOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-314-5416
Mailing Address - Street 1:3022 JAVIER RD STE 105E
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4646
Mailing Address - Country:US
Mailing Address - Phone:614-314-5416
Mailing Address - Fax:
Practice Address - Street 1:3022 JAVIER RD STE 105E
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4646
Practice Address - Country:US
Practice Address - Phone:614-314-5416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH201921703994OtherHOME CARE