Healthcare Provider Details

I. General information

NPI: 1295497709
Provider Name (Legal Business Name): NICOLE MICHELLE MARSHALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 INDUSTRIAL DR
GLOUCESTER VA
23061-3767
US

IV. Provider business mailing address

6031 INDUSTRIAL DR
GLOUCESTER VA
23061-3767
US

V. Phone/Fax

Practice location:
  • Phone: 804-210-1368
  • Fax: 804-684-3691
Mailing address:
  • Phone: 804-210-1368
  • Fax: 804-684-3691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024182942
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: