Healthcare Provider Details

I. General information

NPI: 1386693422
Provider Name (Legal Business Name): ROBERTA ANN SERRA CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001JOHNSON FERRY RD NE
ATLANTA GA
30342
US

IV. Provider business mailing address

2583 ROCKWOOD WAY
STONE MOUNTAIN GA
30087
US

V. Phone/Fax

Practice location:
  • Phone: 404-250-2008
  • Fax: 404-785-4496
Mailing address:
  • Phone: 404-785-2008
  • Fax: 404-785-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR040089NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: