Provider Demographics
NPI:1235320516
Name:PARK, JULIE (FNP)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:703-940-8697
Practice Address - Street 1:1860 TOWN CENTER DR STE 460
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5901
Practice Address - Country:US
Practice Address - Phone:571-222-2200
Practice Address - Fax:712-222-2025
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172648363LF0000X
NYF335014-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC456035ZAN3OtherMEDICARE PTAN
VA1235320516Medicaid