Healthcare Provider Details

I. General information

NPI: 1063080182
Provider Name (Legal Business Name): I-SA NI-KOLE SCOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 SOUTHERN DR
STATESBORO GA
30460-1360
US

IV. Provider business mailing address

950 LANEY WALKER BLVD
AUGUSTA GA
30901-2960
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-4636
  • Fax:
Mailing address:
  • Phone: 706-721-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: