Healthcare Provider Details

I. General information

NPI: 1104608215
Provider Name (Legal Business Name): EMILY TYUS KITCHENS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY STE 200
AUGUSTA GA
30901-2652
US

IV. Provider business mailing address

1030 ALDER WAY APT 311
EVANS GA
30809-9112
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-8940
  • Fax:
Mailing address:
  • Phone: 478-308-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN292748
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD004975
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: