Healthcare Provider Details

I. General information

NPI: 1235320516
Provider Name (Legal Business Name): JULIE PARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR STE 460
RESTON VA
20190-5901
US

IV. Provider business mailing address

3040 WILLIAMS DR STE 100
FAIRFAX VA
22031-4618
US

V. Phone/Fax

Practice location:
  • Phone: 571-222-2200
  • Fax: 712-222-2025
Mailing address:
  • Phone: 571-350-8400
  • Fax: 703-437-6549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024172648
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: