Provider Demographics
NPI:1568015634
Name:YOUNG, SALLY OWIE
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:OWIE
Last Name:YOUNG
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 1:1647 BENNING RD NE
Mailing Address - Street 2:STE 302
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4572
Mailing Address - Country:US
Mailing Address - Phone:202-558-0504
Mailing Address - Fax:
Practice Address - Street 1:223 7TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7045
Practice Address - Country:US
Practice Address - Phone:202-546-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR145430363L00000X
DCRN965271363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner