Provider Demographics
NPI:1720706583
Name:MIREKU, KIERSTIN
Entity Type:Individual
Prefix:
First Name:KIERSTIN
Middle Name:
Last Name:MIREKU
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 1:10521 ROSEHAVEN ST
Mailing Address - Street 2:# 150 LL
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2889
Mailing Address - Country:US
Mailing Address - Phone:703-383-1616
Mailing Address - Fax:703-383-1166
Practice Address - Street 1:10521 ROSEHAVEN ST
Practice Address - Street 2:# 150 LL
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-383-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist