Basic Information
| Provider Information | |||||||||
| NPI: | 1467045096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADBAVNY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCONNELL | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 SWALLOW WAY | ||||||||
| Address2: | |||||||||
| City: | KATHLEEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310473319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312504 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2021 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN069395 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.