Provider Demographics
NPI:1033382148
Name:FAINSAN, NICOLE LEONIE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEONIE
Last Name:FAINSAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:LEONIE
Other - Last Name:FAINSAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11011 BECONTREE LAKE DR
Mailing Address - Street 2:APT 210
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4140
Mailing Address - Country:US
Mailing Address - Phone:571-340-1922
Mailing Address - Fax:
Practice Address - Street 1:150 ELDEN ST
Practice Address - Street 2:SUITE 270
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4861
Practice Address - Country:US
Practice Address - Phone:571-340-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9722225100000X
VA23052076132251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist