Healthcare Provider Details

I. General information

NPI: 1013510080
Provider Name (Legal Business Name): REBECCA JOAN DANIEL AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6751 HIGHLAND POINTE PL
MONROE GA
30656-6228
US

IV. Provider business mailing address

6751 HIGHLAND POINTE PL
MONROE GA
30656-6228
US

V. Phone/Fax

Practice location:
  • Phone: 770-356-9979
  • Fax:
Mailing address:
  • Phone: 770-356-9979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN227497
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN27497
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: