Nicollette Louise Black-Ballard, PMHNP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

290443 Issued in GA

Practice address

5127 Jimmy Carter Blvd Ste 205
Norcross, GA 30093-1619

Phone

(404) 688-1350

NPI assigned

Nov 20, 2024

Last updated

Jan 9, 2025By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Southside Medical Center, Inc

  dba Southside Medical Center School Based Health Center at Lee Elementary School

  • Federally Qualified Health Center (FQHC)
  • Jonesboro, GA
  • NPI 1821981234
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1732060800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1736380800000",
    "number": "1083439541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2915 ILIR MNR NW",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303182231",
            "telephone_number": "404-748-8349"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5127 JIMMY CARTER BLVD STE 205",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300931619",
            "telephone_number": "404-688-1350"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACK-BALLARD",
        "first_name": "NICOLLETTE",
        "middle_name": "LOUISE",
        "credential": "PMHNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-11-20",
        "last_updated": "2025-01-09",
        "certification_date": "2025-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "GA",
            "license": "290443",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Baracah Binyamin
• Brandie Bishop
• Bismillah Home Care Inc
• Chanel L Bisono
• BJS Wholesale Club Inc (BJS Pharmacy)
• Patricia Ann Blackwell, MD
• Nutta-on Blair, PT, PHD
• Jamie Blake, OT
• Bloom Counseling Services
• Blue Angels Home Care Georgia LLC

• Psychiatric/Mental Health Nurse Practitioner in Norcross, GA
• Providers in Norcross, GA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.