Healthcare Provider Details

I. General information

NPI: 1255331765
Provider Name (Legal Business Name): DEIRDRE Z JOINER-NICHOLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3276 BUFORD DR
BUFORD GA
30519-5702
US

IV. Provider business mailing address

5304 CEDARBROOKE LN
BUFORD GA
30518-9028
US

V. Phone/Fax

Practice location:
  • Phone: 404-251-2890
  • Fax:
Mailing address:
  • Phone: 256-508-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number78854
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: