Healthcare Provider Details

I. General information

NPI: 1801348602
Provider Name (Legal Business Name): MRS. NICOLE DEGRAFFENREID KEMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE DEGRAFFENREID

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 GREENBRIAR PKWY SUITE 117
ATLANTA GA
30331
US

IV. Provider business mailing address

7135 FLETCHER DR
WINSTON GA
30187
US

V. Phone/Fax

Practice location:
  • Phone: 770-653-7609
  • Fax:
Mailing address:
  • Phone: 770-653-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: