Healthcare Provider Details

I. General information

NPI: 1952933285
Provider Name (Legal Business Name): THERESA MOTLEY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK RD STE 570
ATLANTA GA
30342-2807
US

IV. Provider business mailing address

5461 MERIDIAN MARK RD STE 570
ATLANTA GA
30342-2807
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-6895
  • Fax: 404-785-6896
Mailing address:
  • Phone: 404-785-6895
  • Fax: 404-785-6896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN267699
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN267699
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: