Basic Information
| Provider Information | |||||||||
| NPI: | 1184152738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 940 GA HIGHWAY 96 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789881222 | ||||||||
| FaxNumber: | 4789888098 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 GA HIGHWAY 96 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789881222 | ||||||||
| FaxNumber: | 4789888098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | CN0028896141 | GA | Y | Nursing Service Related Providers | Nurse's Aide |
No ID Information.