Provider Demographics
NPI:1871143511
Name:PANDAK, NICOLE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PANDAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 FAVERO RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7037
Mailing Address - Country:US
Mailing Address - Phone:804-360-0672
Mailing Address - Fax:
Practice Address - Street 1:8191 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-2751
Practice Address - Country:US
Practice Address - Phone:804-523-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist