=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891526323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAN LI DNP, APRN, FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2024
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 GALLOWS RD
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22042-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-776-4001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20055 PLACID LAKE TER
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-471-6438
-----------------------------------------------------
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 | R228087
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------