Provider Demographics
NPI:1578960118
Name:GRIFFIN, NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:PA
Mailing Address - Zip Code:19464-6708
Mailing Address - Country:US
Mailing Address - Phone:610-476-9690
Mailing Address - Fax:
Practice Address - Street 1:925 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-1631
Practice Address - Country:US
Practice Address - Phone:267-923-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013619363LF0000X, 363LP0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018444060004Medicaid