Healthcare Provider Details

I. General information

NPI: 1649718784
Provider Name (Legal Business Name): NICOLE LANE HARDEMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LANE HOAG DO

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 MEMORIAL DR STE G2
DALTON GA
30720-8662
US

IV. Provider business mailing address

1107 MEMORIAL DR STE G2
DALTON GA
30720-8662
US

V. Phone/Fax

Practice location:
  • Phone: 706-529-3245
  • Fax: 706-686-8063
Mailing address:
  • Phone: 706-529-3245
  • Fax: 706-686-8221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number93066
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: