Provider Demographics
NPI:1609512292
Name:HARALSON, DEIDRA (NP)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:HARALSON
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 1:15325 BOWMANS FOLLY DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-5476
Mailing Address - Country:US
Mailing Address - Phone:571-455-0079
Mailing Address - Fax:
Practice Address - Street 1:13900 CHURCH HILL DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-2131
Practice Address - Country:US
Practice Address - Phone:703-335-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-07
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily