Provider Demographics
NPI:1184461303
Name:BERNARD, NICKETA
Entity type:Individual
Prefix:
First Name:NICKETA
Middle Name:
Last Name:BERNARD
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 1:7668 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1173
Mailing Address - Country:US
Mailing Address - Phone:919-928-3644
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3050
Practice Address - Country:US
Practice Address - Phone:404-616-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN319192163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical