Provider Demographics
NPI:1679388151
Name:NICKERSON, KATHLEEN (RDH)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9001
Mailing Address - Country:US
Mailing Address - Phone:706-321-6190
Mailing Address - Fax:706-252-3008
Practice Address - Street 1:5601 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9001
Practice Address - Country:US
Practice Address - Phone:706-321-6190
Practice Address - Fax:706-252-3008
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH002903124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist