Provider Demographics
NPI:1922514496
Name:PORTO, NICHELLE TRAXLER (ATC)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:TRAXLER
Last Name:PORTO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:NICHELLE
Other - Middle Name:
Other - Last Name:TRAXLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:228 SILVERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-2847
Mailing Address - Country:US
Mailing Address - Phone:703-966-3637
Mailing Address - Fax:
Practice Address - Street 1:228 SILVERLEAF DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-2847
Practice Address - Country:US
Practice Address - Phone:703-966-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260029292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer