Provider Demographics
NPI:1043874910
Name:BLACK, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 PARK AVE NE APT 1281
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3405
Mailing Address - Country:US
Mailing Address - Phone:810-391-6679
Mailing Address - Fax:
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD STE 1281
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1699
Practice Address - Country:US
Practice Address - Phone:404-257-1589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant