Provider Demographics
NPI:1558953737
Name:NICHOLSON, COLBY LAKE (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:COLBY
Middle Name:LAKE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAKEMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-7791
Mailing Address - Country:US
Mailing Address - Phone:706-289-5132
Mailing Address - Fax:
Practice Address - Street 1:309 VERNON ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3162
Practice Address - Country:US
Practice Address - Phone:706-885-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily