Healthcare Provider Details

I. General information

NPI: 1245875012
Provider Name (Legal Business Name): OMEGA DALE ELLISON HARDY NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OMEGA DALE ELLISON NNP-BC

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 03/18/2023
Certification Date: 03/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HEALTHCARE OF ATLANTA 1405 CLIFTON ROAD NE
ATLANTA GA
30322-1700
US

IV. Provider business mailing address

801 MONTCLAIR RD APT 4220
BIRMINGHAM AL
35213-2005
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1-173540
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN307749
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: