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General NPI Number Information
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NPI Number | 1114200029
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Entity Type | Individual
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Provider Name | BENAISSA KADDOUR DJEBBAR
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Gender | Male
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Dates
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Enumeration Date | 09/27/2011
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Last Update Date | 09/27/2011
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Provider Practice Location Address
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Address Line | 3405 MIKE PADGETT HWY EAST CENTRAL REGIONAL HOSPITAL -FORENSIC UNIT
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City | AUGUSTA
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State | GA
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Zip | 30906-3815
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Country | US
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Telephone | 706-792-7073
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Fax |
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Provider Business Mailing Address
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Address Line | 2060 DUNDEE WAY
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City | GROVETOWN
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State | GA
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Zip | 30813-8124
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Country | US
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Telephone | 706-627-3762
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN 204732
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License Number State | GA
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