Provider Demographics
NPI:1265588271
Name:NICELY, ANN LOUISE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:LOUISE
Last Name:NICELY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:L
Other - Last Name:NICELY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:60 ROXBURY RD
Mailing Address - Street 2:WHITEHALL MEDICAL, PLLC
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8223
Mailing Address - Country:US
Mailing Address - Phone:304-363-6600
Mailing Address - Fax:304-363-7700
Practice Address - Street 1:60 ROXBURY RD
Practice Address - Street 2:WHITEHALL MEDICAL, PLLC
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8223
Practice Address - Country:US
Practice Address - Phone:304-363-6600
Practice Address - Fax:304-363-7700
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00375363A00000X
WV464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVS99643OtherWV WORKER'S COMP
WVP00455326OtherRR MEDICARE
WVNIPA28771Medicare PIN
WVS99643Medicare UPIN