Healthcare Provider Details

I. General information

NPI: 1790195295
Provider Name (Legal Business Name): NICOLE NETTEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 LAKEFIELD DR STE 200
JOHNS CREEK GA
30097-2456
US

IV. Provider business mailing address

1101 NOR TEC DRIVE
CONYERS GA
30013
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-2935
  • Fax:
Mailing address:
  • Phone: 678-374-7514
  • Fax: 678-374-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT7122
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number78351
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: