Healthcare Provider Details

I. General information

NPI: 1225442817
Provider Name (Legal Business Name): NICOLLE ADELE MEDEIROS B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11240 WAPLES MILL RD SUITE 101
FAIRFAX VA
22030-6078
US

IV. Provider business mailing address

1304 N STERLING BLVD
STERLING VA
20164-2322
US

V. Phone/Fax

Practice location:
  • Phone: 703-237-2219
  • Fax: 703-237-2729
Mailing address:
  • Phone: 703-439-4279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: