Healthcare Provider Details

I. General information

NPI: 1942568589
Provider Name (Legal Business Name): KRISTINA GAIL NICHOLS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 DEPUTY BILL CANTRELL MEMORIAL RD STE 100
CUMMING GA
30040-8216
US

IV. Provider business mailing address

3970 DEPUTY BILL CANTRELL MEMORIAL RD STE 100
CUMMING GA
30040-8216
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-2273
  • Fax:
Mailing address:
  • Phone: 678-513-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number156613
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN156613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: