Healthcare Provider Details

I. General information

NPI: 1881233963
Provider Name (Legal Business Name): BERNICE PINKY MONGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 MARKET ST
DULUTH GA
30096-4716
US

IV. Provider business mailing address

1460 APPIAN WAY
LAWRENCEVILLE GA
30046-7663
US

V. Phone/Fax

Practice location:
  • Phone: 678-404-9310
  • Fax:
Mailing address:
  • Phone: 678-237-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN257276
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: