Healthcare Provider Details

I. General information

NPI: 1255639142
Provider Name (Legal Business Name): NICOLE WILBURN STOKES PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE NOEL WILBURN EMT

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 NORTH BLVD W A
DAVENPORT FL
33837-8990
US

IV. Provider business mailing address

3817 ERIC CT
LAKELAND FL
33813-1231
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-9301
  • Fax:
Mailing address:
  • Phone: 863-604-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: