Provider Demographics
NPI:1295438216
Name:MCKNIGHT, NICOLE LASHAYE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LASHAYE
Last Name:MCKNIGHT
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 1:2002 SUMMIT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6422
Mailing Address - Country:US
Mailing Address - Phone:770-637-1359
Mailing Address - Fax:
Practice Address - Street 1:2002 SUMMIT BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-6422
Practice Address - Country:US
Practice Address - Phone:770-637-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025403363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner