1790959351 NPI number — NICOLE K PITTS CRNA

Table of content: NICOLE K PITTS CRNA (NPI 1790959351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790959351 NPI number — NICOLE K PITTS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITTS
Provider First Name:
NICOLE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790959351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204097
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30917-4097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-855-9860
Provider Business Mailing Address Fax Number:
706-860-7124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3651 WHEELER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-855-9860
Provider Business Practice Location Address Fax Number:
706-860-7124
Provider Enumeration Date:
04/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN164688 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)