Provider Demographics
NPI:1235975277
Name:COLVIN, NICOLE LYNN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:COLVIN
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 1:1308 S HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-6913
Mailing Address - Country:US
Mailing Address - Phone:478-553-9099
Mailing Address - Fax:478-553-9518
Practice Address - Street 1:1308 S HARRIS ST
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-6913
Practice Address - Country:US
Practice Address - Phone:478-553-9099
Practice Address - Fax:478-553-9518
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002294156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician