Provider Demographics
NPI:1689763351
Name:ACKLEY, NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ACKLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CHESTNUT STREET EXT STE A
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 CHESTNUT STREET EXT STE A
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2298
Practice Address - Country:US
Practice Address - Phone:814-368-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant