Healthcare Provider Details

I. General information

NPI: 1356865570
Provider Name (Legal Business Name): GEORGINA ANGELINE THOMPSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GEORGINA ANGELINE THREATT

II. Dates (important events)

Enumeration Date: 07/30/2017
Last Update Date: 07/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LLOYD AVE
TYRONE GA
30290-2124
US

IV. Provider business mailing address

75 CORN CRIB DR
NEWNAN GA
30263-6073
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-1200
  • Fax:
Mailing address:
  • Phone: 407-234-9932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN192331
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: