Provider Demographics
NPI:1578878740
Name:BROWN, NICOLE ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BROWN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:705 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-1608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 SAM PERRY BLVD STE 314
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4466
Practice Address - Country:US
Practice Address - Phone:540-374-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110010578363A00000X
CT002420363A00000X, 363AM0700X
TXPA13285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003024205Medicaid
CT003024205Medicaid