Provider Demographics
NPI:1487361572
Name:NICHOLS, MAKEDA (CCMA)
Entity type:Individual
Prefix:
First Name:MAKEDA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:MAKEDA
Other - Middle Name:E
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCMA
Mailing Address - Street 1:185 MISTY RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7615
Mailing Address - Country:US
Mailing Address - Phone:470-896-2226
Mailing Address - Fax:
Practice Address - Street 1:185 MISTY RIDGE TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7615
Practice Address - Country:US
Practice Address - Phone:470-896-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAG2E2W2Q5251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health