Individual
MR. JUSTIN DOYLE NICHOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP-C
Contact information
Practice address
101 RIVERSTONE VIS STE 102, BLUE RIDGE, GA 30513-6630
(706) 258-4140
(706) 258-4141
Mailing address
1835 SAVOY DR STE 300, ATLANTA, GA 30341-1071
(706) 258-4140
(706) 258-4141
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
RN209728
GA
363LF0000X
Family Nurse Practitioner
RN209728
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003202905A
—
GA
05
—
003202905B
—
GA
01
—
G00351A
MEDICARE PTAN
GA
Enumeration date
08/23/2016
Last updated
08/19/2020
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