Healthcare Provider Details

I. General information

NPI: 1568670875
Provider Name (Legal Business Name): MARY WASHINGTON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 LINCOLN JONES RD
ELLENWOOD GA
30294-1828
US

IV. Provider business mailing address

3851 LINCOLN JONES RD
ELLENWOOD GA
30294-1828
US

V. Phone/Fax

Practice location:
  • Phone: 404-494-6764
  • Fax: 404-228-3064
Mailing address:
  • Phone: 404-494-6764
  • Fax: 404-228-3064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN177351
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN177351
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: