Healthcare Provider Details

I. General information

NPI: 1760003842
Provider Name (Legal Business Name): ZACHARY RYAN TIPPENS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 COBB PKWY NW
ACWORTH GA
30101-4178
US

IV. Provider business mailing address

3540 COBB PKWY NW
ACWORTH GA
30101-4178
US

V. Phone/Fax

Practice location:
  • Phone: 770-974-3911
  • Fax: 770-405-0606
Mailing address:
  • Phone: 770-974-3911
  • Fax: 770-405-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9467258
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02200533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: