Provider Demographics
NPI:1710027529
Name:SMITH, NICOLE A (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LOTUS LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6834
Mailing Address - Country:US
Mailing Address - Phone:703-600-9516
Mailing Address - Fax:
Practice Address - Street 1:572 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-3702
Practice Address - Country:US
Practice Address - Phone:540-659-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305204740OtherDHP BOARD PT LICENSE