Healthcare Provider Details

I. General information

NPI: 1053129742
Provider Name (Legal Business Name): REGINA DE LA TORRE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 WESTPARK DR
MC LEAN VA
22102-3109
US

IV. Provider business mailing address

8810 CHURCHFIELD LN
LAUREL MD
20708-2466
US

V. Phone/Fax

Practice location:
  • Phone: 703-287-6400
  • Fax:
Mailing address:
  • Phone: 301-792-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR243312
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: