Provider Demographics
NPI:1881321107
Name:GARNER, NICOLE L (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:GARNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:BEAVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:670 PIERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2579
Mailing Address - Country:US
Mailing Address - Phone:618-206-2094
Mailing Address - Fax:
Practice Address - Street 1:670 PIERCE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2579
Practice Address - Country:US
Practice Address - Phone:618-206-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant