Healthcare Provider Details

I. General information

NPI: 1679136402
Provider Name (Legal Business Name): HEATHER DAYNE LARGO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 MALL OF GEORGIA BLVD STE 107
BUFORD GA
30519-8760
US

IV. Provider business mailing address

2720 MALL OF GEORGIA BLVD STE 107
BUFORD GA
30519-8760
US

V. Phone/Fax

Practice location:
  • Phone: 770-932-2662
  • Fax:
Mailing address:
  • Phone: 404-943-9996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN234910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: