Healthcare Provider Details

I. General information

NPI: 1639584675
Provider Name (Legal Business Name): PEGGY GAIL WHITEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2014
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 RIVER PL STE 501
BRASELTON GA
30517-5600
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-2020
  • Fax: 770-534-8025
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN159770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: