Healthcare Provider Details

I. General information

NPI: 1063803260
Provider Name (Legal Business Name): MAVIS NYARKO YEBOAH WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 CHURCH ST NE
MARIETTA GA
30060-1110
US

IV. Provider business mailing address

699 CHURCH ST NE STE 320
MARIETTA GA
30060-1122
US

V. Phone/Fax

Practice location:
  • Phone: 770-819-9211
  • Fax: 770-819-9161
Mailing address:
  • Phone: 770-819-9211
  • Fax: 770-819-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN181677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: