Provider Demographics
NPI:1720671860
Name:KRALLES, STEPHANIE NICOLE (FNP-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:KRALLES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25314 DILIGENCE CT
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3407
Mailing Address - Country:US
Mailing Address - Phone:301-643-2221
Mailing Address - Fax:
Practice Address - Street 1:8315 LEE HWY STE 202
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2215
Practice Address - Country:US
Practice Address - Phone:703-352-1939
Practice Address - Fax:703-352-2294
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003411363L00000X
VA0024180117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner