Provider Demographics
NPI:1740513118
Name:AMICO, MARIE I (NP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:I
Last Name:AMICO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:I
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:220 CAMPUS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2889
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0125
Practice Address - Street 1:235 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:VA
Practice Address - Zip Code:22851-4112
Practice Address - Country:US
Practice Address - Phone:540-778-4259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017139514363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01540333OtherRR MEDICARE
VAVVB089AMedicare PIN