Healthcare Provider Details

I. General information

NPI: 1902003684
Provider Name (Legal Business Name): NICOLE KOUNALAKIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FY RD NE STE 940A
ATLANTA GA
30342-1609
US

IV. Provider business mailing address

980 JOHNSON FY RD NE STE 940A
ATLANTA GA
30342-1609
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6000
  • Fax:
Mailing address:
  • Phone: 404-851-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number83380
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: