Healthcare Provider Details

I. General information

NPI: 1114290764
Provider Name (Legal Business Name): JILL MELAINE PATRICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MELANIE MORRIS

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PLAZA WAY NW STE E
MARIETTA GA
30060-1141
US

IV. Provider business mailing address

4295 COUNTRY GARDEN WALK NW
KENNESAW GA
30152-2399
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-5101
  • Fax: 770-974-3955
Mailing address:
  • Phone: 770-235-2462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN128940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: