1457402836 NPI number — MS. LAURA RENAE NICHOLS MS - CCC

Table of content: MS. LAURA RENAE NICHOLS MS - CCC (NPI 1457402836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457402836 NPI number — MS. LAURA RENAE NICHOLS MS - CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
LAURA
Provider Middle Name:
RENAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS - CCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RYPKEMA
Provider Other First Name:
LAURA
Provider Other Middle Name:
RENAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457402836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
52 BRIGHTLING LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-298-5892
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52 BRIGHTLING LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-5626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-298-5892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2007

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: 235Z00000X , with the licence number:  YS001970 , 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)

  • Identifier: 342657 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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