Healthcare Provider Details

I. General information

NPI: 1255930806
Provider Name (Legal Business Name): NICOLE PAIGE WOLBERT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PROVIDENCE ST
SPARTA GA
31087-1601
US

IV. Provider business mailing address

60 PROVIDENCE ST
SPARTA GA
31087-1601
US

V. Phone/Fax

Practice location:
  • Phone: 706-444-5153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN215987
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number215987
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: