Basic Information
| Provider Information | |||||||||
| NPI: | 1003583873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEST LIFE VIRGINIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 1ST AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337108102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272012389 | ||||||||
| FaxNumber: | 8552244326 | ||||||||
| Practice Location | |||||||||
| Address1: | 5951 DUGOUT TER | ||||||||
| Address2: | |||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231114570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272012389 | ||||||||
| FaxNumber: | 8552244326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2021 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/CO-FOUNDER | ||||||||
| AuthorizedOfficialTelephone: | 7272012389 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.