Provider Demographics
NPI:1811171515
Name:NICOME, NICOLE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NICOME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7580 SPRINGBOX DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-1287
Mailing Address - Country:US
Mailing Address - Phone:770-306-4457
Mailing Address - Fax:770-774-7218
Practice Address - Street 1:650 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1517
Practice Address - Country:US
Practice Address - Phone:718-596-9800
Practice Address - Fax:718-596-9889
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285393207R00000X
GA060133207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA950906828HMedicaid
NY04528910Medicaid
NY04528910Medicaid