Healthcare Provider Details

I. General information

NPI: 1538167523
Provider Name (Legal Business Name): TONYA B NICHOLSON C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BELLEVUE RD ERIN OFFICE SUITE 26
DUBLIN GA
31021-2885
US

IV. Provider business mailing address

1111 SHAMROCK DR
DUBLIN GA
31021-3096
US

V. Phone/Fax

Practice location:
  • Phone: 478-275-1304
  • Fax:
Mailing address:
  • Phone: 478-998-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberARNP-9165179
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number131379
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: