Provider Demographics
NPI:1811691835
Name:STEWART, NICOLE (CRANIAL PROSTHETIC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:CRANIAL PROSTHETIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 GRAYSON HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5737
Mailing Address - Country:US
Mailing Address - Phone:317-649-3557
Mailing Address - Fax:
Practice Address - Street 1:1205 CAMPBELL RIDGE LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6727
Practice Address - Country:US
Practice Address - Phone:317-608-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier