Provider Demographics
NPI:1821104969
Name:PELHAM, NICOLE COLLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:COLLEEN
Last Name:PELHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:COLLEEN
Other - Last Name:FARLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9172 FINNEGAN ST
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2941
Mailing Address - Country:US
Mailing Address - Phone:703-855-5397
Mailing Address - Fax:
Practice Address - Street 1:2101 E JEFFERSON ST
Practice Address - Street 2:SUITE 6W PPQA
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-5853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160261702Medicaid
TX160261702Medicaid
TX8F2436Medicare ID - Type Unspecified