Healthcare Provider Details

I. General information

NPI: 1154719540
Provider Name (Legal Business Name): ANDRIEA L. MIMBS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR STE 120
MACON GA
31217-3859
US

IV. Provider business mailing address

1835 SAVOY DR STE 300
ATLANTA GA
30341-1071
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-6130
  • Fax: 478-745-4443
Mailing address:
  • Phone: 678-288-9555
  • Fax: 678-288-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number135482
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN135482
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: