Provider Demographics
NPI:1225897598
Name:NICHOLS, SHANTA
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:NICHOLS
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 1:430 COLLIER CRES
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4080
Mailing Address - Country:US
Mailing Address - Phone:757-338-5221
Mailing Address - Fax:
Practice Address - Street 1:523 HILLTOP PLAZA
Practice Address - Street 2:SUITE 24
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4501
Practice Address - Country:US
Practice Address - Phone:757-338-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011767225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist