Provider Demographics
NPI:1285236919
Name:NIELSEN, EDWARD M
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43177 QUILTING LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIDING
Mailing Address - State:VA
Mailing Address - Zip Code:20152
Mailing Address - Country:US
Mailing Address - Phone:703-853-4108
Mailing Address - Fax:
Practice Address - Street 1:2425 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3013
Practice Address - Country:US
Practice Address - Phone:703-689-2570
Practice Address - Fax:844-411-6521
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist