Provider Demographics
NPI:1164768537
Name:CHAVANNES, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHAVANNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 ATLANTA HWY
Mailing Address - Street 2:STE 110-224
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4930
Mailing Address - Country:US
Mailing Address - Phone:678-288-6550
Mailing Address - Fax:678-288-6550
Practice Address - Street 1:5524 OLD NATIONAL HWY
Practice Address - Street 2:STE B
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3341
Practice Address - Country:US
Practice Address - Phone:404-763-8555
Practice Address - Fax:404-763-8502
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN206850163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse