Provider Demographics
NPI:1376765214
Name:PRIDEMORE, NICHOLE JEANETTE (NP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:JEANETTE
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:JEANETTE
Other - Last Name:PRIDEMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:409 WOODRUFF XING # X-ING
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6148
Mailing Address - Country:US
Mailing Address - Phone:419-290-6855
Mailing Address - Fax:
Practice Address - Street 1:1 LETTERMAN DR STE C3500
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-1494
Practice Address - Country:US
Practice Address - Phone:415-612-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH303269363LF0000X
MI4704271769363LF0000X
GA000000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily