Healthcare Provider Details

I. General information

NPI: 1851460265
Provider Name (Legal Business Name): HENRY SANTO INTILI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

268 MOCK CEMETERY RD
BAINBRIDGE GA
39817-6904
US

IV. Provider business mailing address

PO BOX 125
BAINBRIDGE GA
39818-0125
US

V. Phone/Fax

Practice location:
  • Phone: 800-841-0858
  • Fax: 800-841-0858
Mailing address:
  • Phone: 229-246-1428
  • Fax: 229-246-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN123672NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: