Provider Demographics
NPI:1013661347
Name:BOLIVAR-KERNS, JOSEPHINE PANGAN (NP)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:PANGAN
Last Name:BOLIVAR-KERNS
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 1:9299 TOWER SIDE DR APT 438
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-6032
Mailing Address - Country:US
Mailing Address - Phone:414-939-6346
Mailing Address - Fax:
Practice Address - Street 1:9299 TOWER SIDE DR APT 438
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-6032
Practice Address - Country:US
Practice Address - Phone:414-939-6346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily