Healthcare Provider Details

I. General information

NPI: 1629864889
Provider Name (Legal Business Name): NICOLE HEROD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NORTHSIDE FORSYTH DR STE 240
CUMMING GA
30041-6017
US

IV. Provider business mailing address

1400 NORTHSIDE FORSYTH DR STE 240
CUMMING GA
30041-6017
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-0877
  • Fax:
Mailing address:
  • Phone: 770-844-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number295262
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: