Provider Demographics
NPI:1790883502
Name:HELSOM, NICOLE MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:HELSOM
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 1:5750 FALLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7147
Mailing Address - Country:US
Mailing Address - Phone:260-436-8000
Mailing Address - Fax:260-432-5587
Practice Address - Street 1:5750 FALLS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7147
Practice Address - Country:US
Practice Address - Phone:260-436-8000
Practice Address - Fax:260-432-5587
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000849A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000386480OtherBCBS
P00311647OtherMEDICARE RAILROAD
000000386480OtherBCBS
IN204090LMedicare ID - Type Unspecified