Healthcare Provider Details

I. General information

NPI: 1396439402
Provider Name (Legal Business Name): NICOLE ANTOINETTE GRIFFIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 ROSELANE ST NW
MARIETTA GA
30060-6940
US

IV. Provider business mailing address

1518 EZRA CHURCH DR NW
ATLANTA GA
30314-2137
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-9800
  • Fax:
Mailing address:
  • Phone: 404-205-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number0030055145
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: