Healthcare Provider Details

I. General information

NPI: 1467091629
Provider Name (Legal Business Name): DR. CORETTA D. GERVIN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2020
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N WESTOVER BLVD STE D1
ALBANY GA
31707-2102
US

IV. Provider business mailing address

414 N WESTOVER BLVD STE D1
ALBANY GA
31707-2102
US

V. Phone/Fax

Practice location:
  • Phone: 404-710-6646
  • Fax: 229-234-1391
Mailing address:
  • Phone: 404-710-6466
  • Fax: 229-389-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. CORETTA DELIA KEITH
Title or Position: CEO
Credential: DNP, FNP-BC
Phone: 404-710-6646