Healthcare Provider Details

I. General information

NPI: 1639566433
Provider Name (Legal Business Name): KIZZY OLIVER EDMOND FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

IV. Provider business mailing address

854 SHADY GROVE CHURCH RD
DUBLIN GA
31021-1052
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-1190
  • Fax: 478-274-7628
Mailing address:
  • Phone: 478-278-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number230365
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: