Provider Demographics
NPI:1578878740
Name:BROWN, NICOLE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:133 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1726
Practice Address - Country:US
Practice Address - Phone:802-524-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002420363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003024205Medicaid
CT003024205Medicaid