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General NPI Number Information
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NPI Number | 1083439541
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Entity Type | Individual
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Provider Name | NICOLLETTE LOUISE BLACK-BALLARD PMHNP
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Gender | Female
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Dates
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Enumeration Date | 11/20/2024
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Last Update Date | 01/09/2025
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Provider Practice Location Address
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Address Line | 5127 JIMMY CARTER BLVD STE 205
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City | NORCROSS
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State | GA
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Zip | 30093-1619
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Country | US
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Telephone | 404-688-1350
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Fax |
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Provider Business Mailing Address
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Address Line | 2915 ILIR MNR NW
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City | ATLANTA
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State | GA
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Zip | 30318-2231
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Country | US
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Telephone | 404-748-8349
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 290443
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License Number State | GA
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