Provider Demographics
NPI:1942804372
Name:LEE, GRACE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:HYANGGI
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:12190 WAVELAND ST APT 304
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-5569
Mailing Address - Country:US
Mailing Address - Phone:202-286-6700
Mailing Address - Fax:
Practice Address - Street 1:1360 BEVERLY RD STE 200
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3647
Practice Address - Country:US
Practice Address - Phone:703-831-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180355363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health