Provider Demographics
NPI:1205002151
Name:RIVERA, NICOLE T (PA,C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:T
Last Name:RIVERA
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Gender:F
Credentials:PA,C
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Mailing Address - Street 1:1355 PEACHTREE ST NE
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3212
Mailing Address - Country:US
Mailing Address - Phone:678-223-7774
Mailing Address - Fax:678-223-7799
Practice Address - Street 1:900 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1602
Practice Address - Country:US
Practice Address - Phone:770-926-5459
Practice Address - Fax:770-926-4421
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2017-04-19
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Provider Licenses
StateLicense IDTaxonomies
GA005226363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical