Provider Demographics
NPI:1427413285
Name:TOMBLIN, NICKY S (CNM)
Entity Type:Individual
Prefix:MS
First Name:NICKY
Middle Name:S
Last Name:TOMBLIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MRS
Other - First Name:NICKY
Other - Middle Name:S
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1315 JESSE JEWELL PKWY NE STE 200
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3822
Mailing Address - Country:US
Mailing Address - Phone:770-219-9443
Mailing Address - Fax:
Practice Address - Street 1:1315 JESSE JEWELL PKWY NE STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3822
Practice Address - Country:US
Practice Address - Phone:770-219-9443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003494363LW0102X
CANMW235760363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health