Provider Demographics
NPI:1659978104
Name:LEE, SOOJEONG (FNP)
Entity Type:Individual
Prefix:
First Name:SOOJEONG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:SOOJEONG
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8081 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-4724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily