Provider Demographics
NPI:1376924746
Name:NICHOLS, LISA (ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 HENRY ST
Mailing Address - Street 2:#27
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3877
Mailing Address - Country:US
Mailing Address - Phone:404-422-6747
Mailing Address - Fax:
Practice Address - Street 1:1220 W WHEELER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6625
Practice Address - Country:US
Practice Address - Phone:404-422-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA262142612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer