Provider Demographics
NPI:1841500675
Name:WHITE, NICOLLE E (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:E
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3543
Mailing Address - Country:US
Mailing Address - Phone:203-583-8400
Mailing Address - Fax:
Practice Address - Street 1:1918 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3543
Practice Address - Country:US
Practice Address - Phone:203-583-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002437363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002437OtherLICENSE