Provider Demographics
NPI:1710736780
Name:NICKLAUS, ELIZABETH MARIE (CPO)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:NICKLAUS
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 VIKING DR STE E
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7323
Mailing Address - Country:US
Mailing Address - Phone:757-275-8050
Mailing Address - Fax:888-600-5328
Practice Address - Street 1:509 VIKING DR STE E
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7323
Practice Address - Country:US
Practice Address - Phone:757-275-8050
Practice Address - Fax:888-600-5328
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO05072224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist