Provider Demographics
NPI:1447540901
Name:WALCOTT, NEISHELLE D
Entity type:Individual
Prefix:
First Name:NEISHELLE
Middle Name:D
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 LONG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-4404
Mailing Address - Country:US
Mailing Address - Phone:203-274-7426
Mailing Address - Fax:203-720-6550
Practice Address - Street 1:1086 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-4404
Practice Address - Country:US
Practice Address - Phone:203-274-7426
Practice Address - Fax:203-720-6550
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014488-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant