Healthcare Provider Details

I. General information

NPI: 1225159155
Provider Name (Legal Business Name): SOUTHEASTERN GYNECOLOGIC ONCOLOGY ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD NE STE 900
ATLANTA GA
30342-4768
US

IV. Provider business mailing address

980 JOHNSON FERRY RD NE STE 900
ATLANTA GA
30342-4768
US

V. Phone/Fax

Practice location:
  • Phone: 678-420-4100
  • Fax:
Mailing address:
  • Phone: 678-420-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN118553 NP
License Number StateGA

VIII. Authorized Official

Name: MS. NAN CORDIER
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 678-420-4195