Healthcare Provider Details

I. General information

NPI: 1568166346
Provider Name (Legal Business Name): TIFFANY A. NICOLL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 ENTERPRISE CT STE A
COLUMBUS GA
31904-9096
US

IV. Provider business mailing address

106 ENTERPRISE CT STE A
COLUMBUS GA
31904-9096
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-2555
  • Fax:
Mailing address:
  • Phone: 706-321-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number112298
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: