Healthcare Provider Details

I. General information

NPI: 1730492323
Provider Name (Legal Business Name): NICOLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW
WASHINGTON DC
20422-0001
US

IV. Provider business mailing address

1400 IRVING ST NW APT 712
WASHINGTON DC
20010-2882
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: NICOLE GABRIELLE WILSON
Title or Position: INTERN
Credential:
Phone: 707-704-3165