Provider Demographics
NPI:1649074634
Name:FAMA, NICOLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FAMA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9217
Mailing Address - Country:US
Mailing Address - Phone:304-573-1567
Mailing Address - Fax:
Practice Address - Street 1:1920 W 1ST ST FL 3
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4220
Practice Address - Country:US
Practice Address - Phone:336-716-4479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program