Provider Demographics
NPI:1164909420
Name:MILLEDGE, NIKOVIA
Entity Type:Individual
Prefix:
First Name:NIKOVIA
Middle Name:
Last Name:MILLEDGE
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 1:3131 N OAK STREET EXT APT 12F
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1075
Mailing Address - Country:US
Mailing Address - Phone:793-489-5955
Mailing Address - Fax:
Practice Address - Street 1:3131 N OAK STREET EXT APT 12F
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1075
Practice Address - Country:US
Practice Address - Phone:793-489-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA393794103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool