Provider Demographics
NPI:1417919408
Name:MODZELESKY, STEPHANIE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:L
Last Name:MODZELESKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL ST., NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:224-D CORNWALL STREET NW, SUITE 204
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2700
Practice Address - Country:US
Practice Address - Phone:571-209-1875
Practice Address - Fax:703-777-3365
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002171363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015904250001Medicaid
VA0110002171OtherLICENSE
VA1417919408Medicaid