MEDICARE: PRANEE CHANTHAVONGSA SMARSH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024177790	VA

General Provider Information

NPI Number	:	1558923060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRANEE CHANTHAVONGSA SMARSH NP

Provider Business Mailing Address
First Line	:	PO BOX 37174
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21297-3174
Country	:	US
Telephone Number	:	571-423-5699
Fax Number	:

Provider Business Practice Location Address
First Line	:	1488 NORTHPOINT VILLAGE CTR
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20194-1190
Country	:	US
Telephone Number	:	571-525-5850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	08/08/2022

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