MEDICARE: LENA MARGARETA MIKULAK FNP

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	0024167634	VA

General Provider Information

NPI Number	:	1710162029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENA MARGARETA MIKULAK FNP

Provider Business Mailing Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1000
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-352-3344
Fax Number	:	703-796-1918

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1000
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-352-3344
Fax Number	:	703-796-1918

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

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	01/04/2008

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