Provider Demographics
NPI:1336371525
Name:YESHTOKIN, NICOLE F (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:F
Last Name:YESHTOKIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DESIMONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2232 WILBORN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1662
Mailing Address - Country:US
Mailing Address - Phone:434-517-3910
Mailing Address - Fax:434-517-3912
Practice Address - Street 1:22232 WILBORN AVE STE C
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-517-3910
Practice Address - Fax:434-517-3912
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0T013281208600000X
NC2020-04156208600000X
VA0102203996208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery