Provider Demographics
NPI:1154656668
Name:TAN, SOKUNTHY
Entity Type:Individual
Prefix:MRS
First Name:SOKUNTHY
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 BRANDON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2504
Mailing Address - Country:US
Mailing Address - Phone:703-913-4774
Mailing Address - Fax:
Practice Address - Street 1:6120 BRANDON AVE STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2504
Practice Address - Country:US
Practice Address - Phone:703-913-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA20-0576591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist