Provider Demographics
NPI:1396439402
Name:GRIFFIN, NICOLE ANTOINETTE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANTOINETTE
Last Name:GRIFFIN
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 1:1518 EZRA CHURCH DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-2137
Mailing Address - Country:US
Mailing Address - Phone:404-205-2963
Mailing Address - Fax:
Practice Address - Street 1:613 ROSELANE ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6940
Practice Address - Country:US
Practice Address - Phone:770-792-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0030055145374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide