Healthcare Provider Details

I. General information

NPI: 1124780861
Provider Name (Legal Business Name): DELIVERANCE HEALTH LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CRESCENT WOODE DR
DALLAS GA
30157-5725
US

IV. Provider business mailing address

108 CRESCENT WOODE DR
DALLAS GA
30157-5725
US

V. Phone/Fax

Practice location:
  • Phone: 404-934-6010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EBOTE N NNOKO
Title or Position: OWNER
Credential:
Phone: 404-934-6010