Healthcare Provider Details

I. General information

NPI: 1801136593
Provider Name (Legal Business Name): TRICIA W THACKSTON RN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

IV. Provider business mailing address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-3200
  • Fax:
Mailing address:
  • Phone: 404-616-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN154255
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN154255
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: