Provider Demographics
NPI:1285819326
Name:PAUKSTA, NICOLLETTE LEIGH (BSN, RN, CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:LEIGH
Last Name:PAUKSTA
Suffix:
Gender:F
Credentials:BSN, RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6122
Practice Address - Fax:864-560-6276
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC078458367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00846188OtherRAILROAD MEDICARE
SCAN1652Medicaid
SCQ34679Medicare UPIN
SCAN1652Medicaid