Provider Demographics
NPI:1205229689
Name:PHAN, LYSA (L AC)
Entity Type:Individual
Prefix:
First Name:LYSA
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6540 ARLINGTON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-6638
Mailing Address - Country:US
Mailing Address - Phone:703-533-2249
Mailing Address - Fax:
Practice Address - Street 1:6540 ARLINGTON BLVD STE B
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-6638
Practice Address - Country:US
Practice Address - Phone:703-533-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA012100210171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty