Healthcare Provider Details

I. General information

NPI: 1306538426
Provider Name (Legal Business Name): EMILY LOUISE OTHOLD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 W MARIETTA ST NW
ATLANTA GA
30318-5252
US

IV. Provider business mailing address

47 SHORTLEAF TRL
RICHMOND HILL GA
31324-6555
US

V. Phone/Fax

Practice location:
  • Phone: 888-772-0076
  • Fax:
Mailing address:
  • Phone: 774-218-0741
  • Fax: 774-218-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN242072
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: