MEDICARE: MRS. NICOLE MARIE SORRELLS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN9232361	FL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11014332	FL
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	GAA-NP001721	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407426760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE MARIE SORRELLS APRN

Provider Business Mailing Address
First Line	:	6060 LAKE ACWORTH DR NW STE H
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-7358
Country	:	US
Telephone Number	:	561-568-4556
Fax Number	:

Provider Business Practice Location Address
First Line	:	6060 LAKE ACWORTH DR NW STE H
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-7358
Country	:	US
Telephone Number	:	561-568-4556
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/18/2025

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