Healthcare Provider Details

I. General information

NPI: 1679028575
Provider Name (Legal Business Name): GRACE TAMU FOMUNUNG NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE CAROTHERS

II. Dates (important events)

Enumeration Date: 08/20/2016
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 THIMBLEBERRY TRL
DACULA GA
30019-7299
US

IV. Provider business mailing address

3206 THIMBLEBERRY TRL
DACULA GA
30019-7299
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-7338
  • Fax:
Mailing address:
  • Phone: 404-819-7338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN201867
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN201867
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: