Healthcare Provider Details

I. General information

NPI: 1588245138
Provider Name (Legal Business Name): LYNNE CONATSER CAMAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 150
CANTON GA
30115-8018
US

IV. Provider business mailing address

460 NORTHSIDE CHEROKEE BLVD STE 150
CANTON GA
30115-8018
US

V. Phone/Fax

Practice location:
  • Phone: 470-639-6350
  • Fax: 770-345-0712
Mailing address:
  • Phone: 470-639-6350
  • Fax: 770-345-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberRN091685
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN091685
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: