Healthcare Provider Details

I. General information

NPI: 1225084783
Provider Name (Legal Business Name): GRACE A NEWSOME NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 TIPTON DR
DAHLONEGA GA
30533-1603
US

IV. Provider business mailing address

330 RIVER OVERLOOK RD
DAWSONVILLE GA
30534-5794
US

V. Phone/Fax

Practice location:
  • Phone: 706-864-4012
  • Fax: 706-864-4029
Mailing address:
  • Phone: 706-265-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN037772
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: