Healthcare Provider Details

I. General information

NPI: 1407376650
Provider Name (Legal Business Name): KENDALL JAMES NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE FL 4
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

420 DELAWARE STREET SE MMC 295, DEPARTMENT OF NEUROLOGY
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-7533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number97548
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: