Provider Demographics
NPI:1447771977
Name:FREEMAN, NICOLE CORINNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CORINNE
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CORINNE
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:26251 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-3540
Mailing Address - Country:US
Mailing Address - Phone:804-296-5887
Mailing Address - Fax:
Practice Address - Street 1:26251 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-3540
Practice Address - Country:US
Practice Address - Phone:804-296-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA63460958172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver