Healthcare Provider Details

I. General information

NPI: 1619506300
Provider Name (Legal Business Name): HOLYSTICK,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 01/18/2026
Certification Date: 01/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 ROUTE 29 STE 720
FAIRFAX VA
22031-1531
US

IV. Provider business mailing address

14428 HOMECREST RD
SILVER SPRING MD
20906-1820
US

V. Phone/Fax

Practice location:
  • Phone: 703-981-5085
  • Fax: 240-901-4515
Mailing address:
  • Phone: 240-506-6549
  • Fax: 240-901-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HANUL JUNG
Title or Position: CEO
Credential: DOA
Phone: 240-945-8525