Provider Demographics
NPI:1518413475
Name:MCKINNON, NICOLLETTE (FNP-C)
Entity type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:770-832-1488
Mailing Address - Fax:770-836-0051
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-832-1488
Practice Address - Fax:770-836-0051
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily