Healthcare Provider Details

I. General information

NPI: 1447018288
Provider Name (Legal Business Name): GERROD JAMAL GRACIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON ROAD NE EMORY STUDENT HEALTH
ATLANTA GA
30322
US

IV. Provider business mailing address

7 EXECUTIVE PARK DR NE APT 2222
ATLANTA GA
30329-2269
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7551
  • Fax:
Mailing address:
  • Phone: 404-731-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN284674
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: