Individual
LAURA PROVENZANO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3117 DUKE ST, ALEXANDRIA, VA 22314-4518
(703) 751-8800
Mailing address
1563 ONYX DR UNIT 205, MC LEAN, VA 22102-3945
(703) 585-5951
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110004424
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0110004424
STATE LICENSE
VA
Enumeration date
12/10/2012
Last updated
12/12/2017
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