Healthcare Provider Details

I. General information

NPI: 1336769215
Provider Name (Legal Business Name): MARYLOU KAUFFMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 PEACHTREE DUNWOODY RD
ATLANTA GA
30342-1705
US

IV. Provider business mailing address

5505 PEACHTREE DUNWOODY RD
ATLANTA GA
30342-1705
US

V. Phone/Fax

Practice location:
  • Phone: 404-425-1678
  • Fax: 404-325-7404
Mailing address:
  • Phone: 404-425-1678
  • Fax: 404-325-7404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN077940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: