Provider Demographics
NPI:1457615098
Name:NICHOLLS, VICTORIA ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ASHLEY
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ASHLEY
Other - Last Name:BROWNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:2 DULLES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-7320
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:2 DULLES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00284700363AM0700X
PAMA055547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical