Provider Demographics
NPI:1043711435
Name:SONG, STEPHANIE E (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:SONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8644 SUDLEY RD STE 114
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4425
Mailing Address - Country:US
Mailing Address - Phone:703-330-4500
Mailing Address - Fax:
Practice Address - Street 1:8644 SUDLEY RD STE 114
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4425
Practice Address - Country:US
Practice Address - Phone:703-330-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175807363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner