Provider Demographics
NPI:1639767007
Name:BITTLE-OBI, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BITTLE-OBI
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 1:4009 CORNING PL STE E2-106
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-1299
Mailing Address - Country:US
Mailing Address - Phone:704-642-9274
Mailing Address - Fax:
Practice Address - Street 1:345 HUNTINGTON PLACE CT STE 200
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8651
Practice Address - Country:US
Practice Address - Phone:678-782-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBITT-1C6H9363L00000X
GARN232902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner