Healthcare Provider Details

I. General information

NPI: 1437675394
Provider Name (Legal Business Name): JOY THERESA BLUMBERG NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 GREENCASTLE RD
TYRONE GA
30290-2936
US

IV. Provider business mailing address

190 GREENCASTLE RD
TYRONE GA
30290-2936
US

V. Phone/Fax

Practice location:
  • Phone: 770-487-7807
  • Fax:
Mailing address:
  • Phone: 770-487-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN217517
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: