Provider Demographics
NPI:1205477635
Name:THOMAS, NICOLE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 AUTUMN WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8627
Mailing Address - Country:US
Mailing Address - Phone:770-845-0385
Mailing Address - Fax:
Practice Address - Street 1:13025 BIRMINGHAM HWY
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-7306
Practice Address - Country:US
Practice Address - Phone:470-254-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0024702081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine