Healthcare Provider Details

I. General information

NPI: 1326282740
Provider Name (Legal Business Name): NICOLE LYNN ERDLEY LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WESTWOOD AVE
RICHMOND VA
23227-4622
US

IV. Provider business mailing address

4906 DONEGAL TRACE CT
RICHMOND VA
23228-6424
US

V. Phone/Fax

Practice location:
  • Phone: 804-474-1859
  • Fax:
Mailing address:
  • Phone: 804-338-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306601606
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: