Nichelle Gooden
Individual provider Active NPI Driver · Stone Mountain, GA
NPI 1730699208 · NPPES record last updated Oct 10, 2017
Key facts
- NPI
- 1730699208
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Driver 172A00000X
- License
- 058242336 (GA)
- Practice address
- 1408 Colony East Cir
Stone Mountain, GA 30083-5407 - Phone
- (404) 996-9335
- Fax
- (404) 996-9335
- NPI assigned
- Oct 10, 2017
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 058242336 | GA | MD | Driver |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Driver | 172A00000X | 058242336 | GA | Yes |
Addresses
Primary practice location
1408 Colony East Cir
Stone Mountain, GA 30083-5407
Mailing address
PO Box 381
Pine Lake, GA 30072-0381
Phone (404) 996-9335
Other providers in Stone Mountain, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 10, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.