Healthcare Provider Details

I. General information

NPI: 1538421706
Provider Name (Legal Business Name): LAURA NICHOLS REGINBALD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA LAJEAN NICHOLS NP-C

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041
US

IV. Provider business mailing address

1400 NORTHSIDE FORSYTH DR SUITE 310
CUMMING GA
30041-7668
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-3200
  • Fax: 770-844-3227
Mailing address:
  • Phone: 404-365-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN200861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: