Healthcare Provider Details

I. General information

NPI: 1730485194
Provider Name (Legal Business Name): JESSE RAY MAYO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 WINDERMERE PKWY STE 105
CUMMING GA
30041-7033
US

IV. Provider business mailing address

241 OLD ROME RD
KINGSTON GA
30145-2107
US

V. Phone/Fax

Practice location:
  • Phone: 678-455-2800
  • Fax: 770-888-9998
Mailing address:
  • Phone: 706-299-0241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN169618 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: