MEDICARE: NICOLE KOUNALAKIS MD

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	2086X0206X	Surgical Oncology Physician	83380	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902003684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE KOUNALAKIS MD

Provider Business Mailing Address
First Line	:	980 JOHNSON FY RD NE STE 940A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1609
Country	:	US
Telephone Number	:	404-851-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	980 JOHNSON FY RD NE STE 940A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1609
Country	:	US
Telephone Number	:	404-851-6000
Fax Number	:

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

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	07/18/2019

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