Individual
AHRA KO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LSA
Contact information
Practice address
12011 LEE JACKSON MEMORIAL HWY STE 501, FAIRFAX, VA 22033
(703) 349-1379
Mailing address
PO BOX 221135, CHANTILLY, VA 20153-1135
(703) 349-1379
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
Primary
0136000096
VA
Other
Enumeration date
10/25/2012
Last updated
01/28/2022
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