Provider Demographics
NPI:1861668337
Name:SROKA, NICOLE L (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:SROKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:235 NEWHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8607
Mailing Address - Country:US
Mailing Address - Phone:678-628-7177
Mailing Address - Fax:
Practice Address - Street 1:1279 HIGHWAY 54 W
Practice Address - Street 2:SUITE 210
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4550
Practice Address - Country:US
Practice Address - Phone:770-719-5710
Practice Address - Fax:678-817-4360
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57191208600000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty