1811171515 NPI number — NICOLE NICOME MD

Table of content: NICOLE NICOME MD (NPI 1811171515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811171515 NPI number — NICOLE NICOME MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICOME
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1811171515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7580 SPRINGBOX DR
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
FAIRBURN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30213-1287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-306-4457
Provider Business Mailing Address Fax Number:
770-774-7218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 FULTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11217-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-596-9800
Provider Business Practice Location Address Fax Number:
718-596-9889
Provider Enumeration Date:
12/18/2007

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: 207R00000X , with the licence number:  285393 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 060133 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 060133 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 950906828H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04528910 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112378900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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