Healthcare Provider Details

I. General information

NPI: 1487290581
Provider Name (Legal Business Name): FAWN HASTAY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2019
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE FL 6
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1400 TULLIE RD NE FL 6
ATLANTA GA
30329-2309
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax: 404-785-3808
Mailing address:
  • Phone: 404-785-5437
  • Fax: 404-785-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN193498
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: