Healthcare Provider Details

I. General information

NPI: 1376373589
Provider Name (Legal Business Name): PORNTIP NEER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 KING ST STE D
ALEXANDRIA VA
22302-1908
US

IV. Provider business mailing address

5004B BARBOUR DR
ALEXANDRIA VA
22304-7709
US

V. Phone/Fax

Practice location:
  • Phone: 855-910-3278
  • Fax:
Mailing address:
  • Phone: 571-274-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024190843
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: