Healthcare Provider Details

I. General information

NPI: 1124378054
Provider Name (Legal Business Name): RENEE AZIZA MULENDWE GAY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON RD NE
ATLANTA GA
30322-4200
US

IV. Provider business mailing address

1525 CLIFTON RD NE STE 408
ATLANTA GA
30322-4200
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4451
  • Fax:
Mailing address:
  • Phone: 404-778-4451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number225307
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number225307
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: