Healthcare Provider Details

I. General information

NPI: 1053925107
Provider Name (Legal Business Name): BRENDALYNE FACIA TAMBA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2020
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 RESOURCE PKWY
WINDER GA
30680-8364
US

IV. Provider business mailing address

595 HURRICANE SHOALS RD NW STE 100
LAWRENCEVILLE GA
30046-8762
US

V. Phone/Fax

Practice location:
  • Phone: 770-291-0419
  • Fax: 240-348-8500
Mailing address:
  • Phone: 404-645-7150
  • Fax: 678-433-9152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN207407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: