=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073885133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA-LISA MARIE TARABICOS FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2012
-----------------------------------------------------
Last Update Date | 02/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3795 MANSELL RD
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-8247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-612-9301
-----------------------------------------------------
Fax | 678-884-8100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 470 SADDLEBROOK DR
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30075-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-612-9301
-----------------------------------------------------
Fax | 678-884-8100
-----------------------------------------------------
=====================================================
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 | RN148036
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------