Healthcare Provider Details

I. General information

NPI: 1073909990
Provider Name (Legal Business Name): NICOLE CLAIRE VISSICHELLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST BOX 980509
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

1250 E MARSHALL ST BOX 980509
RICHMOND VA
23298-5051
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-8786
  • Fax: 804-828-5466
Mailing address:
  • Phone: 804-828-8786
  • Fax: 804-828-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0101269044
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: