Healthcare Provider Details

I. General information

NPI: 1629167580
Provider Name (Legal Business Name): MARY GUMP FLY ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 DRUID PARK AVE
AUGUSTA GA
30904-5849
US

IV. Provider business mailing address

1231 GLENN AVE
AUGUSTA GA
30904-4615
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-6485
  • Fax:
Mailing address:
  • Phone: 706-736-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN163789
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: