Healthcare Provider Details

I. General information

NPI: 1497387633
Provider Name (Legal Business Name): MARGARET BRONAUGH SPORN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date: 02/07/2020
Reactivation Date: 02/19/2020

III. Provider practice location address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

IV. Provider business mailing address

1468 MONTREAL RD
TUCKER GA
30084-6901
US

V. Phone/Fax

Practice location:
  • Phone: 770-638-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN258801
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: