=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053806760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER NICOLE NUETZEL FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3646 CHAMBLEE TUCKER RD STE B
-----------------------------------------------------
City | CHAMBLEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-493-6767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2709 E SUDBURY CT
-----------------------------------------------------
City | DUNWOODY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30360-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN198340
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------