Provider Demographics
NPI:1598126179
Name:NIBLACK, TEMICA BOHANNON
Entity Type:Individual
Prefix:MRS
First Name:TEMICA
Middle Name:BOHANNON
Last Name:NIBLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TEMICA
Other - Middle Name:TERESE
Other - Last Name:BOHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:100 HALCYON CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HALCYON CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-5375
Practice Address - Country:US
Practice Address - Phone:770-241-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN157878363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology