Healthcare Provider Details

I. General information

NPI: 1457195877
Provider Name (Legal Business Name): SAE JEONG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 FRANKLIN RD SW
ROANOKE VA
24014-1111
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-510-6200
  • Fax:
Mailing address:
  • Phone: 540-224-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024190174
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: