Healthcare Provider Details

I. General information

NPI: 1104358803
Provider Name (Legal Business Name): SIMONE KEINIA SHARP-BUCKNOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOUNT ZION PKWY
JONESBORO GA
30236-2500
US

IV. Provider business mailing address

2400 MOUNT ZION PKWY
JONESBORO GA
30236-2500
US

V. Phone/Fax

Practice location:
  • Phone: 470-303-4249
  • Fax: 770-603-3675
Mailing address:
  • Phone: 470-303-4249
  • Fax: 770-603-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN150311
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberRN150311
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: