Provider Demographics
NPI:1215955059
Name:VINCELETTE, NICOLE ELIZABETH (PA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:VINCELETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:HORNUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4980 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE A2-130
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5545
Mailing Address - Country:US
Mailing Address - Phone:480-215-3035
Mailing Address - Fax:
Practice Address - Street 1:4980 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE A2-130
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-5545
Practice Address - Country:US
Practice Address - Phone:480-215-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ137146Medicaid
P94130Medicare UPIN