Provider Demographics
NPI:1669992657
Name:SLOAN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SLOAN
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 1:240 OLD STATE ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-3401
Mailing Address - Country:US
Mailing Address - Phone:229-289-2163
Mailing Address - Fax:
Practice Address - Street 1:240 OLD STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791
Practice Address - Country:US
Practice Address - Phone:229-289-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4362363A00000X
GA008550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant