Provider Demographics
NPI:1457806184
Name:NICHOLSON, JUSTIN DOYLE (NP-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DOYLE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:706-258-4140
Mailing Address - Fax:706-258-4141
Practice Address - Street 1:101 RIVERSTONE VIS STE 102
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6630
Practice Address - Country:US
Practice Address - Phone:706-258-4140
Practice Address - Fax:706-258-4141
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209728363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG00351AOtherMEDICARE PTAN
GA003202905BMedicaid
GA003202905AMedicaid