Provider Demographics
NPI:1043368756
Name:NIX, KIJANA NICOLA (MD,FAAP)
Entity Type:Individual
Prefix:
First Name:KIJANA
Middle Name:NICOLA
Last Name:NIX
Suffix:
Gender:F
Credentials:MD,FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SAM PERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4453
Mailing Address - Country:US
Mailing Address - Phone:540-741-3303
Mailing Address - Fax:
Practice Address - Street 1:455 S MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4354
Practice Address - Country:US
Practice Address - Phone:912-408-6868
Practice Address - Fax:912-876-6566
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67353208000000X
GA56610208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA123310847AMedicaid
GAI50939Medicare UPIN
GA37BBHCPMedicare ID - Type Unspecified