Healthcare Provider Details

I. General information

NPI: 1568897767
Provider Name (Legal Business Name): TARA PHELPS GULSBY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3869 HIGHWAY 81
LOGANVILLE GA
30052-3918
US

IV. Provider business mailing address

1001 SUMMIT BLVD STE 200
BROOKHAVEN GA
30319-6410
US

V. Phone/Fax

Practice location:
  • Phone: 678-635-8650
  • Fax:
Mailing address:
  • Phone: 770-989-1668
  • Fax: 678-388-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN209319
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN209319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: