Healthcare Provider Details

I. General information

NPI: 1831812056
Provider Name (Legal Business Name): REBECCA ANNE BOOKER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 GWINNETT DR
LAWRENCEVILLE GA
30046-5671
US

IV. Provider business mailing address

6706 90TH ST
LUBBOCK TX
79424-6729
US

V. Phone/Fax

Practice location:
  • Phone: 770-910-9196
  • Fax: 770-910-9197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number787163
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberGAA-NP002105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: