Provider Demographics
NPI:1093983660
Name:LEE, SUNGNYU SHIN (PT)
Entity Type:Individual
Prefix:
First Name:SUNGNYU
Middle Name:SHIN
Last Name:LEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 MEREWORTH CT
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-1758
Mailing Address - Country:US
Mailing Address - Phone:703-626-1465
Mailing Address - Fax:703-319-7972
Practice Address - Street 1:3102 MEREWORTH CT
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-1758
Practice Address - Country:US
Practice Address - Phone:703-626-1465
Practice Address - Fax:703-319-7972
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305203083OtherP.T LICENSE