Provider Demographics
NPI:1407009418
Name:WALL, NICHOELLE RENEE (PA)
Entity Type:Individual
Prefix:MISS
First Name:NICHOELLE
Middle Name:RENEE
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:NICHOELLE
Other - Middle Name:RENEE
Other - Last Name:GOURLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:589 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6600
Mailing Address - Country:US
Mailing Address - Phone:541-567-1717
Mailing Address - Fax:541-564-5994
Practice Address - Street 1:5304 N ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8078
Practice Address - Country:US
Practice Address - Phone:509-543-9300
Practice Address - Fax:509-542-3059
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant