Provider Demographics
NPI:1093227480
Name:YOUNG, NICOLE VIRGIEANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VIRGIEANN
Last Name:YOUNG
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 1:13305 GARDEN STATE DR APT B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-5712
Mailing Address - Country:US
Mailing Address - Phone:757-570-5078
Mailing Address - Fax:
Practice Address - Street 1:13305 GARDEN STATE DR APT B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-5712
Practice Address - Country:US
Practice Address - Phone:757-570-5078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3256853343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)