Provider Demographics
NPI:1578998878
Name:PEANASKY, NICHOLE KAY
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:KAY
Last Name:PEANASKY
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 1:2665 N DECATUR RD STE 520
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6146
Mailing Address - Country:US
Mailing Address - Phone:404-299-2223
Mailing Address - Fax:404-297-5003
Practice Address - Street 1:2665 N DECATUR RD STE 520
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6146
Practice Address - Country:US
Practice Address - Phone:404-299-2223
Practice Address - Fax:404-297-5003
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012819363LA2200X
GARN214615363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health