Healthcare Provider Details

I. General information

NPI: 1366993149
Provider Name (Legal Business Name): STACY EBERHART NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KENNESAW AVE NW STE 200
MARIETTA GA
30060-7940
US

IV. Provider business mailing address

1068 COUNTY ROAD 816
WEDOWEE AL
36278-6234
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6490
  • Fax:
Mailing address:
  • Phone: 404-376-5801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number189163
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number189163
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: