Healthcare Provider Details

I. General information

NPI: 1649906454
Provider Name (Legal Business Name): MARISA WONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4358
US

IV. Provider business mailing address

8525 TYSONS CT
VIENNA VA
22182-5019
US

V. Phone/Fax

Practice location:
  • Phone: 703-280-2841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024177055
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: