Provider Demographics
NPI:1730632290
Name:WILSON, NICHELLE J (AUD, CCC-A)
Entity type:Individual
Prefix:DR
First Name:NICHELLE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-0176
Mailing Address - Country:US
Mailing Address - Phone:678-741-5310
Mailing Address - Fax:866-278-2672
Practice Address - Street 1:3400 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:678-741-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD004014231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08122016222502OtherNPPES HEALTHCARE FACILITY