Healthcare Provider Details

I. General information

NPI: 1194042036
Provider Name (Legal Business Name): ALICE JACQUELINE HASKINS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HIGHWAY 155 N
MCDONOUGH GA
30252-4846
US

IV. Provider business mailing address

3333 RIVERWOOD PKWY SE STE 250
ATLANTA GA
30339-3304
US

V. Phone/Fax

Practice location:
  • Phone: 678-490-0341
  • Fax: 678-490-0349
Mailing address:
  • Phone: 770-914-0116
  • Fax: 770-955-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5010499
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN286041
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number234600
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: