Healthcare Provider Details

I. General information

NPI: 1396836722
Provider Name (Legal Business Name): RUTH L TELLANO-DANIEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 CLEAR CREEK PKWY
LAVONIA GA
30553-4173
US

IV. Provider business mailing address

204 RIDGEWOOD LN
HARTWELL GA
30643-4146
US

V. Phone/Fax

Practice location:
  • Phone: 706-356-7800
  • Fax:
Mailing address:
  • Phone: 864-787-4418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2360
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: