Provider Demographics
NPI:1518196369
Name:HENN, NICOLE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:HENN
Suffix:
Gender:F
Credentials:PA-C
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 209
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68702-0209
Mailing Address - Country:US
Mailing Address - Phone:402-379-2322
Mailing Address - Fax:402-379-9533
Practice Address - Street 1:2222 S 16TH ST STE 240
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3764
Practice Address - Country:US
Practice Address - Phone:402-323-7260
Practice Address - Fax:402-323-7266
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1454OtherPHYSICIAN ASSISTANT LICENSE
NE10026139600Medicaid