Healthcare Provider Details

I. General information

NPI: 1205114105
Provider Name (Legal Business Name): NICOLE B SANDRIDGE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13048 RIVERS BEND RD
CHESTER VA
23836-2564
US

IV. Provider business mailing address

13000 RIVERS BEND BLVD STE D
CHESTER VA
23836-8632
US

V. Phone/Fax

Practice location:
  • Phone: 804-523-0333
  • Fax: 804-530-9998
Mailing address:
  • Phone: 804-571-5106
  • Fax: 804-530-1857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305206997
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: