Healthcare Provider Details

I. General information

NPI: 1801489711
Provider Name (Legal Business Name): YOUR NURSE PRACTITIONER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4360 SHORE DR STE 101
VIRGINIA BEACH VA
23455-2994
US

IV. Provider business mailing address

4360 SHORE DR STE 101
VIRGINIA BEACH VA
23455-2994
US

V. Phone/Fax

Practice location:
  • Phone: 757-251-0879
  • Fax: 984-220-9437
Mailing address:
  • Phone: 757-251-0879
  • Fax: 984-220-9437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XH1300X
TaxonomyHuman Factors Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SANDRA W NICHOLS
Title or Position: CEO
Credential: PHD, APRN
Phone: 757-251-0879