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BLUE MANTLE MEDICINE PLLC
NPI 1417658980
Pediatrics in Fairfax, VA

Active since March 13, 2023CLIA 49D2280070 · Waiver
4001 FAIR RIDGE DR STE 305, FAIRFAX, VA 22033(540) 701-4767(703) 520-9880 Get Directions Write a Review

NPPES record last updated: March 13, 2023. Verified against the NPPES registry weekly; last sync: August 16, 2026.

About Blue Mantle Medicine Pllc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

BLUE MANTLE MEDICINE PLLC (NPI 1417658980) is a healthcare organization registered as a pediatrics in Fairfax, Virginia and active in the NPI registry since March 2023. The organization holds a CLIA Waiver certificate valid through April 11, 2027 and lists Sita Canady, Md, as its authorized official.

NPPES Registry Identity

NPI1417658980
Entity TypeOrganization
Primary Taxonomy208000000X
Legal Business NameBLUE MANTLE MEDICINE PLLC
Location Address4001 FAIR RIDGE DR STE 305Fairfax, VA 22033-2917
Mailing Address4001 Fair Ridge Dr Ste 305Fairfax, VA 22033-2917 · (540) 701-4767 · Fax (703) 520-9880
Phone(540) 701-4767
Fax(703) 520-9880
Organization SubpartNo
Authorized OfficialSita CanadyMd · (540) 645-1856
Enumeration DateMarch 13, 2023
NPPES CertifiedMarch 13, 2023
✔ NPI 1417658980 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPediatricsAllopathic & Osteopathic Physicians
Taxonomy Code208000000X
Definition
A pediatrician is concerned with the physical, emotional and social health of children from birth to young adulthood. Care encompasses a broad spectrum of health services ranging from preventive healthcare to the diagnosis and treatment of acute and chronic diseases. A pediatrician deals with biological, social and environmental influences on the developing child, and with the impact of disease and dysfunction on development.
4001 FAIR RIDGE DR STE 305, Fairfax, VA 22033
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Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 49D2280070

Blue Mantle Medicine, PLLC · Fairfax, VA
Active · expires Apr 11, 2027
CLIA Number49D2280070
Laboratory TypePhysician Office
Certificate Effective DateApril 12, 2025
Certificate Expiration DateApril 11, 2027
Laboratory DirectorSita S. Canady
Laboratory Phone(540) 645-1856
Laboratory LocationBlue Mantle Medicine, PLLC4001 Fair Ridge Dr, Suite #305, Fairfax, VA 22033
CLIA data matches this NPI record on: Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 3

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

DR. CAROLE WARREN SEBENICK PH.D.
Psychologist (Clinical)
4001 FAIR RIDGE DR STE 305
FAIRFAX, VA 22033
Fairfax County (703) 362-9313
DR. MICHAEL R. HRYVNIAK M.D.
Psychiatry & Neurology (Psychiatry)
4001 FAIR RIDGE DR STE 305
FAIRFAX, VA 22033
Fairfax County (703) 448-3133
MICHAEL R. HRYVNIAK, M.D., P.C.
Psychiatry & Neurology (Psychiatry)
4001 FAIR RIDGE DR STE 305
FAIRFAX, VA 22033
Fairfax County (703) 448-3133

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Blue Mantle Medicine PLLC's NPI number?

The NPI number for Blue Mantle Medicine PLLC is 1417658980. It was assigned to this organization in the NPPES registry on March 13, 2023.

Where is Blue Mantle Medicine PLLC located?

Blue Mantle Medicine PLLC is located at 4001 Fair Ridge Dr Ste 305, Fairfax, VA 22033. The listed phone number is (540) 701-4767.

What is Blue Mantle Medicine PLLC's specialty?

The primary specialty registered for this NPI is Pediatrics with taxonomy code 208000000X.

Does Blue Mantle Medicine PLLC hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 49D2280070) is associated with this NPI, valid through April 11, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Blue Mantle Medicine PLLC was last updated on March 13, 2023. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 3 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.