Healthcare Provider Details

I. General information

NPI: 1124338876
Provider Name (Legal Business Name): PERTINNA DAVIS HUDSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 NORTH AVE
ATLANTA GA
30308
US

IV. Provider business mailing address

10624 EAGLE DR
JONESBORO GA
30238-6685
US

V. Phone/Fax

Practice location:
  • Phone: 404-607-7677
  • Fax:
Mailing address:
  • Phone: 678-526-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN160448NP
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberRN160448 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: