Provider Demographics
NPI:1598702102
Name:EARLEY, NICOLE B (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:B
Last Name:EARLEY
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:103 SOLANA ROAD SUITE B
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082
Mailing Address - Country:US
Mailing Address - Phone:904-273-2717
Mailing Address - Fax:904-273-0410
Practice Address - Street 1:103 SOLANA ROAD SUITE B
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082
Practice Address - Country:US
Practice Address - Phone:904-273-2717
Practice Address - Fax:904-273-0410
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9102362363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ18974Medicare UPIN