Healthcare Provider Details

I. General information

NPI: 1245179092
Provider Name (Legal Business Name): MARVO BRENDA PROSPER AZILLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 ELDON DR
FAIRBURN GA
30213-5806
US

IV. Provider business mailing address

4104 ELDON DR
FAIRBURN GA
30213-5806
US

V. Phone/Fax

Practice location:
  • Phone: 470-443-7128
  • Fax:
Mailing address:
  • Phone: 470-443-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN320202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: