Healthcare Provider Details

I. General information

NPI: 1720300387
Provider Name (Legal Business Name): FAMILY FIRST HEALTHCARE OF NORTHEAST GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11973 AUGUSTA RD
LAVONIA GA
30553-1283
US

IV. Provider business mailing address

11973 AUGUSTA RD
LAVONIA GA
30553-1283
US

V. Phone/Fax

Practice location:
  • Phone: 706-356-8181
  • Fax: 706-356-8081
Mailing address:
  • Phone: 706-356-8181
  • Fax: 706-356-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN144697NP
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN144697NP
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN144697NP
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN144697NP
License Number StateGA

VIII. Authorized Official

Name: NICOLE FORD
Title or Position: OFFICE MANAGER
Credential: NP
Phone: 706-356-8181