Healthcare Provider Details

I. General information

NPI: 1457818015
Provider Name (Legal Business Name): ELIZABETH PERSEPHONE ANDERSEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7813 SPIVEY STATION BLVD STE 210
LAKE SPIVEY GA
30236-2900
US

IV. Provider business mailing address

1100 JOHNSON FERRY RD STE 510
SANDY SPRINGS GA
30342-1743
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-0070
  • Fax:
Mailing address:
  • Phone: 404-419-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN228808
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018080794
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: