Healthcare Provider Details

I. General information

NPI: 1407342603
Provider Name (Legal Business Name): MARY GRACE B NUEGA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

1835 SAVOY DR STE 300
ATLANTA GA
30341-1071
US

V. Phone/Fax

Practice location:
  • Phone: 404-367-3014
  • Fax: 770-942-7699
Mailing address:
  • Phone: 678-288-9555
  • Fax: 678-288-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN157187
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberC-APN.0102426-C-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN157187
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1135487
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN157187
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN157187
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number291745
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: