Healthcare Provider Details

I. General information

NPI: 1679878466
Provider Name (Legal Business Name): MRS. LAURICE DAWN REPKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 GREEN ST NW
GAINESVILLE GA
30501-3374
US

IV. Provider business mailing address

4167 CUMBERLAND POINT DR
GAINESVILLE GA
30504-5351
US

V. Phone/Fax

Practice location:
  • Phone: 678-936-7080
  • Fax:
Mailing address:
  • Phone: 770-297-1461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 002429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: