Provider Demographics
NPI:1245581677
Name:KELLNER, NICOLE MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:KELLNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MICHELLE
Other - Last Name:MOLCHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 402924
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2924
Mailing Address - Country:US
Mailing Address - Phone:804-320-2705
Mailing Address - Fax:804-330-2433
Practice Address - Street 1:40 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9289
Practice Address - Country:US
Practice Address - Phone:804-520-6730
Practice Address - Fax:804-520-6731
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004771363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical