Healthcare Provider Details

I. General information

NPI: 1851951958
Provider Name (Legal Business Name): MARYAH RENEE TRUSS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3088 WASHINGTON RD
EAST POINT GA
30344-4566
US

IV. Provider business mailing address

PO BOX 740015
ATLANTA GA
30374-0015
US

V. Phone/Fax

Practice location:
  • Phone: 470-444-3135
  • Fax: 404-777-9336
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9227
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019333
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN301563
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: