Healthcare Provider Details

I. General information

NPI: 1629960927
Provider Name (Legal Business Name): GWENDOLYN QUYNH ANH NGUYEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 PRINCE WILLIAM PKWY
WOODBRIDGE VA
22192-4145
US

IV. Provider business mailing address

2924 PRINCE WILLIAM PKWY
WOODBRIDGE VA
22192-4145
US

V. Phone/Fax

Practice location:
  • Phone: 703-763-1390
  • Fax: 703-763-1395
Mailing address:
  • Phone: 703-763-1390
  • Fax: 703-763-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003545
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: