Healthcare Provider Details

I. General information

NPI: 1316361835
Provider Name (Legal Business Name): ANNA TUPKO MALOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 1170
LAWRENCEVILLE GA
30046-1170
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9000
  • Fax:
Mailing address:
  • Phone: 470-325-0159
  • Fax: 470-325-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number200462
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN198112
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: