Provider Demographics
NPI:1104911841
Name:NICHOLAS, IRENE S
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:S
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 HERITAGE TRL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4897
Mailing Address - Country:US
Mailing Address - Phone:404-433-4657
Mailing Address - Fax:770-650-2713
Practice Address - Street 1:6325 W JOHNS XING
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5746
Practice Address - Country:US
Practice Address - Phone:404-778-8311
Practice Address - Fax:404-495-1585
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN096684367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCBVW43Medicare ID - Type Unspecified