=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649906454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA WONG FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2022
-----------------------------------------------------
Last Update Date | 08/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 PROSPERITY AVE STE 200
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-280-2841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8525 TYSONS CT
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-5019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024177055
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------