Basic Information
| Provider Information | |||||||||
| NPI: | 1558781179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | GEORGINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 96 JONATHAN LUCAS STREET CSB 423A/MSC 613 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294250001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437922098 | ||||||||
| FaxNumber: | 8437924523 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 JONATHAN LUCAS ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294254607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437922098 | ||||||||
| FaxNumber: | 8437924523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2014 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 38436 | SC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.