Healthcare Provider Details

I. General information

NPI: 1679264675
Provider Name (Legal Business Name): AZEB KIDANE TKIKIL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

IV. Provider business mailing address

150 CHESSINGTON DR
ALPHARETTA GA
30022-4521
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax:
Mailing address:
  • Phone: 678-469-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN278333
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN278333
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN278333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: