Healthcare Provider Details

I. General information

NPI: 1518104769
Provider Name (Legal Business Name): ABBY DAWN MUTIC CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 CLIFTON RD NE
ATLANTA GA
30322-4201
US

IV. Provider business mailing address

1520 CLIFTON RD NE OFC 370
ATLANTA GA
30322-4201
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7980
  • Fax:
Mailing address:
  • Phone: 404-727-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2004021997
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2004021997
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: