Healthcare Provider Details

I. General information

NPI: 1336003615
Provider Name (Legal Business Name): NICOLE A BRISTOL APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 TEXAS SKY DR
GEORGETOWN TX
78628-7333
US

IV. Provider business mailing address

417 TEXAS SKY DR
GEORGETOWN TX
78628-7333
US

V. Phone/Fax

Practice location:
  • Phone: 802-272-7000
  • Fax:
Mailing address:
  • Phone: 802-272-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1229330
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0138991
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: