Healthcare Provider Details

I. General information

NPI: 1518717891
Provider Name (Legal Business Name): ADA APPOLONIA OFFOR PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

PO BOX 2773
PEACHTREE CITY GA
30269-0773
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone: 404-455-5963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN153547
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: