Provider Demographics
NPI:1386055705
Name:NICHOLSON, JULIE TIERNEY (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:TIERNEY
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:RIVERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 WOODPARK PL STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3705
Mailing Address - Country:US
Mailing Address - Phone:770-926-4150
Mailing Address - Fax:770-926-0594
Practice Address - Street 1:203 WOODPARK PL STE 100
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3705
Practice Address - Country:US
Practice Address - Phone:770-926-4150
Practice Address - Fax:770-926-0594
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87263207Q00000X
GA98300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC872639Medicaid