Healthcare Provider Details

I. General information

NPI: 1710736780
Provider Name (Legal Business Name): ELIZABETH MARIE NICKLAUS CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 VIKING DR STE E
VIRGINIA BEACH VA
23452-7323
US

IV. Provider business mailing address

509 VIKING DR STE E
VIRGINIA BEACH VA
23452-7323
US

V. Phone/Fax

Practice location:
  • Phone: 757-275-8050
  • Fax: 888-600-5328
Mailing address:
  • Phone: 757-275-8050
  • Fax: 888-600-5328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO05072
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO05072
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: