Healthcare Provider Details

I. General information

NPI: 1265595482
Provider Name (Legal Business Name): DOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 FARRELL RD
FORT BELVOIR VA
22060-5901
US

IV. Provider business mailing address

8637 HILLSIDE MANOR DR
SPRINGFIELD VA
22152-2240
US

V. Phone/Fax

Practice location:
  • Phone: 703-805-0067
  • Fax:
Mailing address:
  • Phone: 703-752-1776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number0001109410
License Number StateVA

VIII. Authorized Official

Name: MRS. KYUNG OK PARK
Title or Position: CLINICAL NURSE
Credential: BSN
Phone: 703-805-0067