=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083377014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAYA REGINA TROCHECK FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2021
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1561 LENRU RD STE A
-----------------------------------------------------
City | BOGART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30622-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-725-2399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4910 GODDARDS FORD RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30504-5128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-745-1506
-----------------------------------------------------
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 | RN280827
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------