Healthcare Provider Details

I. General information

NPI: 1215726740
Provider Name (Legal Business Name): BRIANNA TAYLOR NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

420 TOPGOLF WAY
AUGUSTA GA
30909-0354
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17458
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: