Healthcare Provider Details

I. General information

NPI: 1083583967
Provider Name (Legal Business Name): BOAZ LEE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

13820 BRADDOCK SPRINGS RD APT A
CENTREVILLE VA
20121-4212
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-4001
  • Fax:
Mailing address:
  • Phone: 571-730-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number0001318200
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: