MEDICARE: NICOLE ELISE HEIDARAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0024175152	VA

General Provider Information

NPI Number	:	1902329568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ELISE HEIDARAN

Provider Business Mailing Address
First Line	:	1488 NORTHPOINT VILLAGE CTR
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20194-1190
Country	:	US
Telephone Number	:	571-786-1024
Fax Number	:	571-786-1025

Provider Business Practice Location Address
First Line	:	1488 NORTHPOINT VILLAGE CTR
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20194-1190
Country	:	US
Telephone Number	:	571-780-1024
Fax Number	:	571-786-1025

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	03/09/2023

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Directions to “ NICOLE ELISE HEIDARAN ” Practice Location

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