Provider Demographics
NPI:1558641670
Name:NICKS, LILLIAN MISHELLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LILLIAN
Middle Name:MISHELLE
Last Name:NICKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-603-6300
Mailing Address - Fax:864-603-6160
Practice Address - Street 1:104 INNOVATION DR
Practice Address - Street 2:SUITE 2000
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5253
Practice Address - Country:US
Practice Address - Phone:864-603-6300
Practice Address - Fax:864-603-6160
Is Sole Proprietor?:No
Enumeration Date:2011-08-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2272Medicaid