Healthcare Provider Details

I. General information

NPI: 1679369086
Provider Name (Legal Business Name): NICOLE K BALLEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 VIRGINIA BEACH BLVD # A
VIRGINIA BEACH VA
23462-5631
US

IV. Provider business mailing address

5604 VIRGINIA BEACH BLVD # A
VIRGINIA BEACH VA
23462-5631
US

V. Phone/Fax

Practice location:
  • Phone: 757-455-5000
  • Fax:
Mailing address:
  • Phone: 757-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012245
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: