Healthcare Provider Details

I. General information

NPI: 1073822482
Provider Name (Legal Business Name): NICOL LYNN SCHWANDT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2010
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 FAIRFAX BLVD
FAIRFAX VA
22030
US

IV. Provider business mailing address

PO BOX 758963
BALTIMORE MD
21275-8963
US

V. Phone/Fax

Practice location:
  • Phone: 703-679-1876
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003745
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: