Provider Demographics
NPI:1003496605
Name:COBB, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:COBB
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 1:1402 LAKE WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-8222
Mailing Address - Country:US
Mailing Address - Phone:304-615-9248
Mailing Address - Fax:
Practice Address - Street 1:1402 LAKE WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:WV
Practice Address - Zip Code:26181-8222
Practice Address - Country:US
Practice Address - Phone:304-615-9248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant