=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700506144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALIKATA NICOLETTE DANO NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 10/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 QUARTZ DR STE 103B
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-812-3530
-----------------------------------------------------
Fax | 770-812-3579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5778 WEMBLEY DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-852-1333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN-NP195658
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------