1477502110 NPI number — MS. PENELYNNE TAN FLORES FNP

Table of content: MRS. EMILY WEAVER CRNP (NPI 1326481987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477502110 NPI number — MS. PENELYNNE TAN FLORES FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLORES
Provider First Name:
PENELYNNE
Provider Middle Name:
TAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477502110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44320 PREMIER PLAZA
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-5077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-723-8727
Provider Business Mailing Address Fax Number:
703-723-9787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44320 PREMIER PLAZA
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
ASHBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20147-5077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-723-8727
Provider Business Practice Location Address Fax Number:
703-723-9787
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  24164883 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7790732 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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