Healthcare Provider Details

I. General information

NPI: 1699245704
Provider Name (Legal Business Name): WILLIAM CLINTON STOREY FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 E LAMAR ST
AMERICUS GA
31709-3738
US

IV. Provider business mailing address

108 SPRING DR
PRESTON GA
31824-3458
US

V. Phone/Fax

Practice location:
  • Phone: 229-928-8355
  • Fax:
Mailing address:
  • Phone: 770-366-3536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN248678
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN248678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: