Provider Demographics
NPI:1952736449
Name:WILSON, NICOLE M (PHARMD, BCOP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD, BCOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 STEVE REYNOLDS BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:770-931-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0250141835X0200X
IN26021742A1835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology