Provider Demographics
NPI:1780040055
Name:SCHULTZ, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LEFEBVRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 KINROSS DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-6736
Mailing Address - Country:US
Mailing Address - Phone:603-978-5648
Mailing Address - Fax:
Practice Address - Street 1:152 LINDEN DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2818
Practice Address - Country:US
Practice Address - Phone:540-667-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-02
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9663363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVK518AMedicare PIN