MEDICARE: MRS. ELAINA MIRANDA AVERETT FNP-BC

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	363LF0000X	Family Nurse Practitioner	RN218486	GA

General Provider Information

NPI Number	:	1811558901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELAINA MIRANDA AVERETT FNP-BC

Provider Business Mailing Address
First Line	:	580 HAMPTON FARMS TRL
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-5571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 HAMPTON FARMS TRL
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-5571
Country	:	US
Telephone Number	:	770-894-7820
Fax Number	:

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

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	06/28/2019

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