Healthcare Provider Details

I. General information

NPI: 1104469733
Provider Name (Legal Business Name): NICOLE BAKER CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2019
Last Update Date: 10/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7703
  • Fax: 757-668-8860
Mailing address:
  • Phone: 757-668-7703
  • Fax: 757-668-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024176636
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: