Basic Information
Provider Information | |||||||||
NPI: | 1295133767 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKER | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARKER | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | LILLIAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1557 JANMAR RD | ||||||||
Address2: |   | ||||||||
City: | SNELLVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300785686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783448900 | ||||||||
FaxNumber: | 6786665201 | ||||||||
Practice Location | |||||||||
Address1: | 1133 EAGLES LANDING PKWY | ||||||||
Address2: |   | ||||||||
City: | STOCKBRIDGE | ||||||||
State: | GA | ||||||||
PostalCode: | 302815085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6786041053 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2014 | ||||||||
LastUpdateDate: | 06/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN204290 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | RN204290 | 01 | GA | GEORGIA BOARD OF NURSING | OTHER |