Healthcare Provider Details

I. General information

NPI: 1679859391
Provider Name (Legal Business Name): NIKKI LYNN MAYETTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI LYNN SERGE PA-C

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S MAIN ST SUITE 2 SOUTH
DOYLESTOWN PA
18901-4870
US

IV. Provider business mailing address

301 S MAIN ST SUITE 2 SOUTH
DOYLESTOWN PA
18901-4870
US

V. Phone/Fax

Practice location:
  • Phone: 215-348-4478
  • Fax: 215-348-2452
Mailing address:
  • Phone: 215-348-4478
  • Fax: 215-348-2452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA055147
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: