Provider Demographics
NPI:1750026928
Name:GANOW, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:GANOW
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 1:8663 WOODWARD RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20115-3349
Mailing Address - Country:US
Mailing Address - Phone:703-932-1161
Mailing Address - Fax:
Practice Address - Street 1:12581 MILSTEAD WAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5445
Practice Address - Country:US
Practice Address - Phone:703-239-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program