Healthcare Provider Details

I. General information

NPI: 1134630858
Provider Name (Legal Business Name): MARJORIE YVETTE ELIBERT CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HANDLEY RD STE A
TYRONE GA
30290
US

IV. Provider business mailing address

190 HANDLEY RD STE A
TYRONE GA
30290-2178
US

V. Phone/Fax

Practice location:
  • Phone: 770-997-5714
  • Fax: 770-997-5828
Mailing address:
  • Phone: 770-997-5714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberRN184038
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN184038
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberRN184038
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: