Healthcare Provider Details

I. General information

NPI: 1134519077
Provider Name (Legal Business Name): MADE WHOLE HEALTHCARE SOLUTIONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 GILLIONVILLE RD
ALBANY GA
31721-6271
US

IV. Provider business mailing address

PO BOX 71802
ALBANY GA
31708-1802
US

V. Phone/Fax

Practice location:
  • Phone: 229-483-0020
  • Fax: 229-483-0021
Mailing address:
  • Phone: 770-330-8496
  • Fax: 229-888-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRN131505
License Number StateGA

VIII. Authorized Official

Name: NEDRA S FORTSON
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 770-330-8496