Healthcare Provider Details

I. General information

NPI: 1134732969
Provider Name (Legal Business Name): STEPHANIE VINNIKOV B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CARPENTER DR STE 210
STERLING VA
20164-4468
US

IV. Provider business mailing address

5840 CAMERON RUN TER APT 804
ALEXANDRIA VA
22303-1853
US

V. Phone/Fax

Practice location:
  • Phone: 703-297-4368
  • Fax:
Mailing address:
  • Phone: 732-668-5064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: