Provider Demographics
NPI:1093311490
Name:GRANDJEAN, IRINA (FNP-C)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:GRANDJEAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 POTOMAC TOWN PL STE 110
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4095
Mailing Address - Country:US
Mailing Address - Phone:540-351-0662
Mailing Address - Fax:
Practice Address - Street 1:14900 POTOMAC TOWN PL STE 110
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4095
Practice Address - Country:US
Practice Address - Phone:540-351-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017321363LF0000X
VA0024179569363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily