Healthcare Provider Details

I. General information

NPI: 1063907228
Provider Name (Legal Business Name): MISS NICOLE NEVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 PORTSMOUTH BLVD STE B
CHESAPEAKE VA
23321-2154
US

IV. Provider business mailing address

2924 E POINT DR
CHESAPEAKE VA
23321-4104
US

V. Phone/Fax

Practice location:
  • Phone: 757-292-4774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: