Healthcare Provider Details

I. General information

NPI: 1134426596
Provider Name (Legal Business Name): LOLA Y COSBY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3603 CRAWFORDVILLE DR
AUGUSTA GA
30909-9462
US

IV. Provider business mailing address

3603 CRAWFORDVILLE DR
AUGUSTA GA
30909-9462
US

V. Phone/Fax

Practice location:
  • Phone: 706-306-1240
  • Fax:
Mailing address:
  • Phone: 706-306-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR51534
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN090851
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: