Provider Demographics
NPI:1912984832
Name:DEBOLT, NICOLE NORRIS (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:NORRIS
Last Name:DEBOLT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 PEACH ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MC CONNELLSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17233-8559
Mailing Address - Country:US
Mailing Address - Phone:814-623-1002
Mailing Address - Fax:814-623-2982
Practice Address - Street 1:214 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:MC CONNELLSBURG
Practice Address - State:PA
Practice Address - Zip Code:17233-8559
Practice Address - Country:US
Practice Address - Phone:814-623-1002
Practice Address - Fax:814-623-2982
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDO 1023208600000X
PAOS015694208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD 000Medicare UPIN