MEDICARE: ATHENA NEWELL NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	AP138047	TX
2	363LF0000X	Family Nurse Practitioner	287975	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	287975	OTHER	GA	STATE LICENSE
2	46-4599729	OTHER		FAMILY PRACTICE

General Provider Information

NPI Number	:	1699251587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ATHENA NEWELL NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1465 HOWELL MILL RD NW STE 300A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4246
Country	:	US
Telephone Number	:	850-582-1810
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 HOWELL MILL RD NW STE 300A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4246
Country	:	US
Telephone Number	:	850-582-1810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2018
Last Update Date	:	11/14/2019

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