Provider Demographics
NPI:1720200728
Name:PELLICCIOTTO, NICOLE ALYSSA (MED, ABD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALYSSA
Last Name:PELLICCIOTTO
Suffix:
Gender:F
Credentials:MED, ABD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:PELLICCIOTTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, ABD
Mailing Address - Street 1:11642 LEEHIGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5640
Mailing Address - Country:US
Mailing Address - Phone:703-819-4697
Mailing Address - Fax:
Practice Address - Street 1:11642 LEEHIGH DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5640
Practice Address - Country:US
Practice Address - Phone:703-819-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA222Q00000XOtherDEVELOPMENTAL