Healthcare Provider Details

I. General information

NPI: 1912243726
Provider Name (Legal Business Name): MELBA KIDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

IV. Provider business mailing address

1290 ATHENS ST
GAINESVILLE GA
30507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 770-531-5611
  • Fax:
Mailing address:
  • Phone: 770-531-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN086988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: