Provider Demographics
NPI:1508497298
Name:FALL, NICOLE G
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:FALL
Suffix:
Gender:F
Credentials:
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 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-544-4060
Mailing Address - Fax:
Practice Address - Street 1:1324 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536
Practice Address - Country:US
Practice Address - Phone:843-544-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid