Provider Demographics
NPI:1750695904
Name:NICKELSON, JULIE A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:IVANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2767 OLIVE HWY
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6118
Mailing Address - Country:US
Mailing Address - Phone:530-533-8500
Mailing Address - Fax:530-532-8370
Practice Address - Street 1:2767 OLIVE HWY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6118
Practice Address - Country:US
Practice Address - Phone:530-533-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant