Provider Demographics
NPI:1144491937
Name:NICHOLS, MEMORIE MORGAN (PA-C)
Entity type:Individual
Prefix:
First Name:MEMORIE
Middle Name:MORGAN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4550
Mailing Address - Country:US
Mailing Address - Phone:770-719-5710
Mailing Address - Fax:
Practice Address - Street 1:1279 HIGHWAY 54 W
Practice Address - Street 2:SUITE 210
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4550
Practice Address - Country:US
Practice Address - Phone:770-719-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant