Healthcare Provider Details

I. General information

NPI: 1346840089
Provider Name (Legal Business Name): OPAL GLORIEN BAYONNE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 MAPLE TERRACE DR
SUWANEE GA
30024-2487
US

IV. Provider business mailing address

3430 MAPLE TERRACE DR
SUWANEE GA
30024-2487
US

V. Phone/Fax

Practice location:
  • Phone: 678-628-3919
  • Fax:
Mailing address:
  • Phone: 678-628-3919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP203490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: