Healthcare Provider Details

I. General information

NPI: 1821231861
Provider Name (Legal Business Name): BERTINE METAGO LUNDBERG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BERTINE METAGO LPN

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

V. Phone/Fax

Practice location:
  • Phone: 404-367-3014
  • Fax:
Mailing address:
  • Phone: 404-367-3014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN245551
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number296527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: