Provider Demographics
NPI:1710504279
Name:NICHOLSON, STEPHANIE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:NICHOLSON
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:PO BOX 1741
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0030
Mailing Address - Country:US
Mailing Address - Phone:910-316-0415
Mailing Address - Fax:
Practice Address - Street 1:104 BUILDERS PKWY
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-5396
Practice Address - Country:US
Practice Address - Phone:678-616-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist