Healthcare Provider Details

I. General information

NPI: 1760003842
Provider Name (Legal Business Name): ZACHARY RYAN TIPPENS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 TRANSIT AVE
CANTON GA
30114-2540
US

IV. Provider business mailing address

720 TRANSIT AVE
CANTON GA
30114-2540
US

V. Phone/Fax

Practice location:
  • Phone: 770-720-7000
  • Fax: 770-720-7055
Mailing address:
  • Phone: 770-720-7000
  • Fax: 770-720-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP239947
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN239947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: