Provider Demographics
NPI:1114544525
Name:WARNER, NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WARNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FY RD NE STE 180
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1795
Mailing Address - Country:US
Mailing Address - Phone:404-250-6691
Mailing Address - Fax:
Practice Address - Street 1:1100 JOHNSON FY RD NE STE 180
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1795
Practice Address - Country:US
Practice Address - Phone:404-250-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant