Healthcare Provider Details

I. General information

NPI: 1457409112
Provider Name (Legal Business Name): MICHELLE YVONNE STEVENS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

IV. Provider business mailing address

11598 LAGRANGE LN
KING GEORGE VA
22485-6611
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3400
  • Fax: 703-519-6505
Mailing address:
  • Phone: 540-775-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002030994
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: