Healthcare Provider Details

I. General information

NPI: 1972356061
Provider Name (Legal Business Name): ROXANN ELAINE DEEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 05/15/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 US HIGHWAY 82 W STE 5
TIFTON GA
31793-8213
US

IV. Provider business mailing address

1909 US HIGHWAY 82 W STE 5
TIFTON GA
31793-8213
US

V. Phone/Fax

Practice location:
  • Phone: 229-386-4300
  • Fax: 229-386-8300
Mailing address:
  • Phone: 229-386-4300
  • Fax: 229-386-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN239888
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: