Provider Demographics
NPI:1629601448
Name:VAN, LIA H (NP)
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:H
Last Name:VAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 PENDER DR STE 170
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6066
Mailing Address - Country:US
Mailing Address - Phone:703-261-6220
Mailing Address - Fax:
Practice Address - Street 1:3702 PENDER DR STE 170
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6066
Practice Address - Country:US
Practice Address - Phone:703-261-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003005363LF0000X
VA0024178838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily