Provider Demographics
NPI:1275150518
Name:SOISTMAN, GRACE ANDALES
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANDALES
Last Name:SOISTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 BOONE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2681
Mailing Address - Country:US
Mailing Address - Phone:571-290-1084
Mailing Address - Fax:571-786-2419
Practice Address - Street 1:8300 BOONE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2681
Practice Address - Country:US
Practice Address - Phone:571-290-1084
Practice Address - Fax:571-786-2419
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNP500008490363LF0000X, 363LP0808X
VA0024179630363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily