Provider Demographics
NPI:1477502110
Name:FLORES, PENELYNNE TAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:PENELYNNE
Middle Name:TAN
Last Name:FLORES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:44320 PREMIER PLAZA
Mailing Address - Street 2:STE 110
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5077
Mailing Address - Country:US
Mailing Address - Phone:703-723-8727
Mailing Address - Fax:703-723-9787
Practice Address - Street 1:44320 PREMIER PLAZA
Practice Address - Street 2:STE 110
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5077
Practice Address - Country:US
Practice Address - Phone:703-723-8727
Practice Address - Fax:703-723-9787
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24164883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7790732Medicaid
VA017624R25Medicare PIN