Provider Demographics
NPI:1588330575
Name:NICHOLS, LYNDSEY BROOKE (DPT)
Entity type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:BROOKE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SPRING ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3773
Mailing Address - Country:US
Mailing Address - Phone:770-615-7676
Mailing Address - Fax:
Practice Address - Street 1:500 SPRING ST SE STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3773
Practice Address - Country:US
Practice Address - Phone:770-615-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0155442251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA841619876Medicaid