Provider Demographics
NPI:1457402836
Name:NICHOLS, LAURA RENAE (MS - CCC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:RENAE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS - CCC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:RENAE
Other - Last Name:RYPKEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 BRIGHTLING LN
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5626
Mailing Address - Country:US
Mailing Address - Phone:770-298-5892
Mailing Address - Fax:
Practice Address - Street 1:52 BRIGHTLING LN
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5626
Practice Address - Country:US
Practice Address - Phone:770-298-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAYS001970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA342657OtherWELLCARE