Provider Demographics
NPI:1295150142
Name:VAN HORN, NICOLETTE
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:VAN HORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:
Other - Last Name:COYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:199 PARK CLUB LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5269
Mailing Address - Country:US
Mailing Address - Phone:716-836-4646
Mailing Address - Fax:
Practice Address - Street 1:921 WAYNE ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2255
Practice Address - Country:US
Practice Address - Phone:716-379-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-02
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016467363A00000X
PAOA003024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant