Provider Demographics
NPI:1710306188
Name:PETERS, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:PETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:DYKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITES 155 AND 390
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-682-6000
Practice Address - Fax:770-513-1103
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant