Healthcare Provider Details

I. General information

NPI: 1790453934
Provider Name (Legal Business Name): ELAINE GRIMES-DIXON APRN, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 HEADLAND DR SW STE 600
ATLANTA GA
30311-5437
US

IV. Provider business mailing address

3030 HEADLAND DR SW STE 600
ATLANTA GA
30311-5437
US

V. Phone/Fax

Practice location:
  • Phone: 470-832-5973
  • Fax: 877-887-5316
Mailing address:
  • Phone: 470-832-5973
  • Fax: 877-887-5316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN183131
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: