Provider Demographics
NPI:1134396005
Name:MORTON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MORTON
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 1:5925 BRADFORD DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2001
Mailing Address - Country:US
Mailing Address - Phone:757-610-7748
Mailing Address - Fax:
Practice Address - Street 1:5925 BRADFORD DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2001
Practice Address - Country:US
Practice Address - Phone:757-855-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-10
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251J00000X, 3747A0650X, 385H00000X
VA1401100481376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No251J00000XAgenciesNursing Care
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134396005Medicaid