Healthcare Provider Details

I. General information

NPI: 1952745275
Provider Name (Legal Business Name): MICHELLE REID FRICKANISCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13478 CARROLLTON BLVD UNITS D & E
CARROLLTON VA
23314-3208
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A RIVERSIDE MEDICAL GROUP
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-238-7043
  • Fax: 757-238-7052
Mailing address:
  • Phone: 757-594-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024170786
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: