Healthcare Provider Details

I. General information

NPI: 1346279833
Provider Name (Legal Business Name): BONNIE JEAN NOCK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/17/2022
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 SOUTH BLVD STE 200
VIRGINIA BEACH VA
23452-1147
US

IV. Provider business mailing address

4525 SOUTH BLVD STE 200
VIRGINIA BEACH VA
23452-1147
US

V. Phone/Fax

Practice location:
  • Phone: 757-227-3820
  • Fax: 757-226-9021
Mailing address:
  • Phone: 757-227-3820
  • Fax: 757-226-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0102049966
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: