Provider Demographics
NPI:1518930700
Name:HORN, NICOLE YVONNE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:YVONNE
Last Name:HORN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2418
Mailing Address - Country:US
Mailing Address - Phone:757-481-2333
Mailing Address - Fax:757-481-1037
Practice Address - Street 1:1120 FIRST COLONIAL RD
Practice Address - Street 2:SUITE100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-481-2333
Practice Address - Fax:757-481-1037
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical