Provider Demographics
NPI:1255639142
Name:STOKES, NICOLE WILBURN (PA-C, ATC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:WILBURN
Last Name:STOKES
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:NOEL
Other - Last Name:WILBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EMT
Mailing Address - Street 1:3817 ERIC CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1231
Mailing Address - Country:US
Mailing Address - Phone:863-604-1235
Mailing Address - Fax:
Practice Address - Street 1:2231 NORTH BLVD W
Practice Address - Street 2:A
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-419-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105879363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical