Healthcare Provider Details

I. General information

NPI: 1568187367
Provider Name (Legal Business Name): TERESA FAYE BREWER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 JESSE JEWELL PKWY SE STE A
GAINESVILLE GA
30501-3857
US

IV. Provider business mailing address

825 JESSE JEWELL PKWY SE STE A
GAINESVILLE GA
30501-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-7574
  • Fax: 770-219-7575
Mailing address:
  • Phone: 770-219-7574
  • Fax: 770-219-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberLC000113
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: