Provider Demographics
NPI:1609597053
Name:SCOTT, NICOLE ELISE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELISE
Last Name:SCOTT
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 1:6054 LAMP POST PL
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-8820
Mailing Address - Country:US
Mailing Address - Phone:770-557-5144
Mailing Address - Fax:
Practice Address - Street 1:4910 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2085
Practice Address - Country:US
Practice Address - Phone:770-557-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 332B00000X
GA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171400000XOther Service ProvidersHealth & Wellness Coach
No332H00000XSuppliersEyewear Supplier