Provider Demographics
NPI:1639225840
Name:VILLA, NICOLE LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:VILLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:ELLINGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:20840 W HUBBELL ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-5521
Mailing Address - Country:US
Mailing Address - Phone:623-341-8758
Mailing Address - Fax:
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:623-547-1899
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ26341Medicare UPIN