Healthcare Provider Details

I. General information

NPI: 1497516629
Provider Name (Legal Business Name): MRS. NAM KYUNG SENERCHIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 06/18/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 SUNRISE VALLEY DR STE 500
RESTON VA
20191-5303
US

IV. Provider business mailing address

2901 TELESTAR CT STE 300
FALLS CHURCH VA
22042-1263
US

V. Phone/Fax

Practice location:
  • Phone: 703-437-5977
  • Fax: 703-478-2475
Mailing address:
  • Phone: 703-591-1688
  • Fax: 703-591-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024189308
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: