Provider Demographics
NPI:1104857093
Name:SHAFFER, NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 W NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7774
Mailing Address - Country:US
Mailing Address - Phone:717-627-2108
Mailing Address - Fax:
Practice Address - Street 1:6 W NEWPORT RD
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7774
Practice Address - Country:US
Practice Address - Phone:717-627-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP005118B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S64992Medicare UPIN
019023Medicare ID - Type Unspecified