Provider Demographics
NPI:1518348556
Name:PEDERSON, NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HANNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7000 FOREST AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3837
Mailing Address - Country:US
Mailing Address - Phone:804-253-9778
Mailing Address - Fax:
Practice Address - Street 1:7000 FOREST AVE STE 500
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3837
Practice Address - Country:US
Practice Address - Phone:804-253-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist