Provider Demographics
NPI:1215228580
Name:HOLWAY, NIKKI ROSE (MED)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:ROSE
Last Name:HOLWAY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5290 DUKE ST
Mailing Address - Street 2:APT. 218
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2933
Mailing Address - Country:US
Mailing Address - Phone:724-787-9077
Mailing Address - Fax:
Practice Address - Street 1:1604 SPRING HILL RD
Practice Address - Street 2:SUITE 310
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-7510
Practice Address - Country:US
Practice Address - Phone:703-546-8594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPRSE-0002134103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst