Provider Demographics
NPI:1316151632
Name:DIRIENZO, NICOLE DANA (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DANA
Last Name:DIRIENZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DIRIENZO
Other - Last Name:HARMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:703-369-8055
Mailing Address - Fax:
Practice Address - Street 1:1020 FIRST COLONIAL RD STE A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3078
Practice Address - Country:US
Practice Address - Phone:757-395-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP606612662084P0800X
VA01022025782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316151632Medicaid
VA1316151632Medicaid