Healthcare Provider Details

I. General information

NPI: 1295630309
Provider Name (Legal Business Name): DERRICK BAHNSEN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

IV. Provider business mailing address

155 HARBEN PL
ATHENS GA
30606-4019
US

V. Phone/Fax

Practice location:
  • Phone: 229-834-4268
  • Fax:
Mailing address:
  • Phone: 229-834-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN328590
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: