Healthcare Provider Details

I. General information

NPI: 1255575890
Provider Name (Legal Business Name): GEORGIA SOUTHERN UNIVERSITY SCHOOL OF NURSING COMMUNITY NURSING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 FORREST DR RM# 1004
STATESBORO GA
30460-0001
US

IV. Provider business mailing address

250 FORREST DR RM# 1004
STATESBORO GA
30460-0001
US

V. Phone/Fax

Practice location:
  • Phone: 912-478-5166
  • Fax: 912-478-5400
Mailing address:
  • Phone: 912-478-5166
  • Fax: 912-478-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberRN117953 NP
License Number StateGA

VIII. Authorized Official

Name: MS. ANGELA DAWNE THOMPSON
Title or Position: DIRECTOR OF NURSING CLINIC
Credential: FNP
Phone: 912-478-5166