Healthcare Provider Details

I. General information

NPI: 1285616979
Provider Name (Legal Business Name): NICOLE MARIE DEYAMPERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 03/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CARPENTER RD
FORT MYER VA
22211-1009
US

IV. Provider business mailing address

401 CARPENTER RD
FORT MYER VA
22211-1009
US

V. Phone/Fax

Practice location:
  • Phone: 703-696-3630
  • Fax:
Mailing address:
  • Phone: 703-696-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD56332
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: