Provider Demographics
NPI:1184972887
Name:NICHOLSON, TERESA (CNM)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 LAKESHORE DR
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3803
Mailing Address - Country:US
Mailing Address - Phone:912-882-7100
Mailing Address - Fax:912-882-9149
Practice Address - Street 1:104 LAKESHORE DR
Practice Address - Street 2:STE A
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3803
Practice Address - Country:US
Practice Address - Phone:912-882-7100
Practice Address - Fax:912-882-9149
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN103935163WG0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127951AMedicaid
GA202I422481OtherMEDICARE PTAN
GA003127951BMedicaid