Basic Information
| Provider Information | |||||||||
| NPI: | 1033198338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEBOYD | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 PIEDMONT AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303032508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047565764 | ||||||||
| FaxNumber: | 4047565252 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 PIEDMONT AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303032508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047565764 | ||||||||
| FaxNumber: | 4047565252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 054452 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | 054452 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 083240704B | 05 | GA | MEDICAID | 083240704C | 05 | GA | MEDICAID |