Provider Demographics
NPI:1972017374
Name:WITT, NICOLE DUBOIS (AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DUBOIS
Last Name:WITT
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6421
Mailing Address - Country:US
Mailing Address - Phone:404-213-0713
Mailing Address - Fax:
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-944-7818
Practice Address - Fax:770-948-9344
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236956363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology