Healthcare Provider Details

I. General information

NPI: 1316863889
Provider Name (Legal Business Name): RUTH AGBOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 COVENANT ST
BETHLEHEM GA
30620-2657
US

IV. Provider business mailing address

452 COVENANT ST
BETHLEHEM GA
30620-2657
US

V. Phone/Fax

Practice location:
  • Phone: 770-369-1037
  • Fax:
Mailing address:
  • Phone: 770-369-1037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN315608
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: