Provider Demographics
NPI:1760172761
Name:SMITH, NICOLE PAULINE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAULINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BUTTERMILK BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-4356
Mailing Address - Country:US
Mailing Address - Phone:908-303-4211
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD STE 215
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6271
Practice Address - Country:US
Practice Address - Phone:610-402-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant