Healthcare Provider Details

I. General information

NPI: 1457523508
Provider Name (Legal Business Name): NICOLE FOBI NUNGA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

3949 S COBB DR SE
SMYRNA GA
30080-6342
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9000
  • Fax: 770-538-7872
Mailing address:
  • Phone: 770-434-0710
  • Fax: 770-801-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number61580
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number001640
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: