Provider Demographics
NPI:1659595171
Name:GOLDBERG, NICOLE S (CPNP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:S
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:S
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1830 TOWN CENTER DR
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3292
Mailing Address - Country:US
Mailing Address - Phone:703-435-3636
Mailing Address - Fax:703-435-9145
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE # 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3292
Practice Address - Country:US
Practice Address - Phone:703-435-3636
Practice Address - Fax:703-435-9145
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165394363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7793588Medicaid