Healthcare Provider Details

I. General information

NPI: 1942804372
Provider Name (Legal Business Name): GRACE LEE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE HYANGGI LEE PMHNP-BC

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR STE 300
RESTON VA
20191-3446
US

IV. Provider business mailing address

12007 SUNRISE VALLEY DR STE 300
RESTON VA
20191-3446
US

V. Phone/Fax

Practice location:
  • Phone: 804-207-6737
  • Fax:
Mailing address:
  • Phone: 804-207-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024180355
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: