Provider Demographics
NPI:1780343137
Name:NOLTON, DEADRE
Entity type:Individual
Prefix:MS
First Name:DEADRE
Middle Name:
Last Name:NOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 HIGHWAY 96 APT 301
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3367
Mailing Address - Country:US
Mailing Address - Phone:478-235-8345
Mailing Address - Fax:
Practice Address - Street 1:940 GA HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2584
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA300089163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty