Healthcare Provider Details

I. General information

NPI: 1649875311
Provider Name (Legal Business Name): JOSE DANNYLO MEJIA JR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WEAVER RD STE B
BLAIRSVILLE GA
30512-3136
US

IV. Provider business mailing address

143 GRACE VALLEY WAY
BLAIRSVILLE GA
30512-4947
US

V. Phone/Fax

Practice location:
  • Phone: 706-439-6165
  • Fax:
Mailing address:
  • Phone: 706-970-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN187555
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10200522
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN187555
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: