Provider Demographics
NPI:1174251524
Name:NIELSEN, NICOLE ASHLEY (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1852
Mailing Address - Street 2:
Mailing Address - City:MAGGIE VALLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28751-1852
Mailing Address - Country:US
Mailing Address - Phone:813-404-1903
Mailing Address - Fax:
Practice Address - Street 1:262 LEROY GEORGE DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7430
Practice Address - Country:US
Practice Address - Phone:828-456-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001012482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant