Healthcare Provider Details

I. General information

NPI: 1073130092
Provider Name (Legal Business Name): NICHELLE LYN KYLES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICHELLE LYN HOOK RN

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

PO BOX 57
MONTMORENCI SC
29839-0057
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 803-249-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number232793
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: