Healthcare Provider Details

I. General information

NPI: 1629519202
Provider Name (Legal Business Name): NURSE PRACTIONER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4044 GEORGE BUSBEE PKWY NW APT 4207
KENNESAW GA
30144-6890
US

IV. Provider business mailing address

PO BOX 1234
POWDER SPRINGS GA
30127-7234
US

V. Phone/Fax

Practice location:
  • Phone: 404-579-1658
  • Fax:
Mailing address:
  • Phone: 404-579-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number193760
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number193760
License Number StateGA

VIII. Authorized Official

Name: ROSE KOMBE
Title or Position: FNP
Credential: NP
Phone: 404-579-1658