Provider Demographics
NPI:1881962389
Name:GODLEWSKI, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:GODLEWSKI
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 1:14660 STATE HIGHWAY 121 STE 100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-4630
Mailing Address - Country:US
Mailing Address - Phone:214-705-6611
Mailing Address - Fax:214-619-1007
Practice Address - Street 1:14660 STATE HIGHWAY 121 STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-4630
Practice Address - Country:US
Practice Address - Phone:214-705-6611
Practice Address - Fax:214-619-1007
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant