Provider Demographics
NPI:1164433892
Name:MARSHALL, NICOLE ANN (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11369 NUCKOLS RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5504
Mailing Address - Country:US
Mailing Address - Phone:804-864-2020
Mailing Address - Fax:804-377-8803
Practice Address - Street 1:11369 NUCKOLS RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5504
Practice Address - Country:US
Practice Address - Phone:804-864-2020
Practice Address - Fax:804-377-8803
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U51227Medicare UPIN