Healthcare Provider Details

I. General information

NPI: 1902108491
Provider Name (Legal Business Name): ROSELINE MAKINDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5808 STATE BRIDGE RD
JOHNS CREEK GA
30097-6476
US

IV. Provider business mailing address

8 CADILLAC DR SUITE 250
BRENTWOOD TN
37027-5087
US

V. Phone/Fax

Practice location:
  • Phone: 678-495-0162
  • Fax:
Mailing address:
  • Phone: 615-425-4287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN162552
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: