Provider Demographics
NPI:1891221966
Name:TANECKA, SUNNY (LAC)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:
Last Name:TANECKA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1313
Mailing Address - Country:US
Mailing Address - Phone:571-305-3136
Mailing Address - Fax:571-989-6233
Practice Address - Street 1:2201 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1313
Practice Address - Country:US
Practice Address - Phone:571-305-3136
Practice Address - Fax:571-989-6233
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2264171100000X
VA0121-001020171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty