Healthcare Provider Details

I. General information

NPI: 1457031205
Provider Name (Legal Business Name): RUTH PHILOGENE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

1083 GATHER DR
LAWRENCEVILLE GA
30043-7553
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 908-313-1049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN300160
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: