Provider Demographics
NPI:1184680241
Name:HARTVIGSEN, NICOLE L (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:HARTVIGSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 N. WASHINGTON STREET
Mailing Address - Street 2:STE. 100
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046
Mailing Address - Country:US
Mailing Address - Phone:703-237-5919
Mailing Address - Fax:703-241-1863
Practice Address - Street 1:407 N. WASHINGTON STREET
Practice Address - Street 2:STE. 100
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046
Practice Address - Country:US
Practice Address - Phone:703-237-5919
Practice Address - Fax:703-241-1863
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007054208000000X
KS04-31628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200332820AMedicaid
MO207198904Medicaid
MO207198904Medicaid
MOI32917Medicare UPIN