MEDICARE: MRS. NICOLE YVONNE HORN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	104142	NC

General Provider Information

NPI Number	:	1518930700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE YVONNE HORN PAC

Provider Business Mailing Address
First Line	:	1120 FIRST COLONIAL RD
Second Line	:	SUITE100
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2418
Country	:	US
Telephone Number	:	757-481-2333
Fax Number	:	757-481-1037

Provider Business Practice Location Address
First Line	:	1120 FIRST COLONIAL RD
Second Line	:	SUITE100
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2418
Country	:	US
Telephone Number	:	757-481-2333
Fax Number	:	757-481-1037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	01/12/2010

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