Healthcare Provider Details

I. General information

NPI: 1346514221
Provider Name (Legal Business Name): JOSHUA MINICH APRN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date: 07/24/2020
Reactivation Date: 01/13/2021

III. Provider practice location address

105 WALNUT ST
MONTEZUMA GA
31063-1902
US

IV. Provider business mailing address

105 WALNUT ST
MONTEZUMA GA
31063-1902
US

V. Phone/Fax

Practice location:
  • Phone: 478-472-4633
  • Fax: 478-472-4637
Mailing address:
  • Phone: 478-472-4633
  • Fax: 478-472-4637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN248941
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: