Provider Demographics
NPI:1598569394
Name:MORTON-EDET, NICOLE A
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:MORTON-EDET
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 MCCLURE BRIDGE RD UNIT 332
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1102
Mailing Address - Country:US
Mailing Address - Phone:510-890-1319
Mailing Address - Fax:
Practice Address - Street 1:514 W MAPLE ST STE 1206
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2536
Practice Address - Country:US
Practice Address - Phone:770-844-8266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA104878164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse