Healthcare Provider Details

I. General information

NPI: 1164697355
Provider Name (Legal Business Name): JOSEPH HENRY KANCLERZ MSN, NP-C, RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOEY KANCLERZ MSN, NP-C, RNFA

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5742 ALLEE WAY
BRASELTON GA
30517-6268
US

IV. Provider business mailing address

PO BOX 7042
CHESTNUT MOUNTAIN GA
30502-0042
US

V. Phone/Fax

Practice location:
  • Phone: 678-591-8344
  • Fax:
Mailing address:
  • Phone: 678-591-8344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN177592
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN177592
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: