Provider Demographics
NPI:1043928930
Name:ANDERSON, NICOLE MARIE (PT, DPT, NCS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:BROWNYARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, NCS
Mailing Address - Street 1:4408 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-1127
Mailing Address - Country:US
Mailing Address - Phone:717-580-6630
Mailing Address - Fax:
Practice Address - Street 1:8191 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-2751
Practice Address - Country:US
Practice Address - Phone:804-523-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE200038OtherNEUROLOGIC CERTIFIED SPECIALIST
VA2305209126OtherBOARD OF PHYSICAL THERAPY