Provider Demographics
NPI:1871714865
Name:NICHOLSON, NICKYLEE JOESPH (DC)
Entity type:Individual
Prefix:DR
First Name:NICKYLEE
Middle Name:JOESPH
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1022
Mailing Address - Country:US
Mailing Address - Phone:770-719-1917
Mailing Address - Fax:
Practice Address - Street 1:155 BRADFORD SQ
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1994
Practice Address - Country:US
Practice Address - Phone:770-719-1917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002265111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor