=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114413002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENAN ELENA OVERTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2018
-----------------------------------------------------
Last Update Date | 07/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 JOHNSON FERRY ROAD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-851-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 BOGUE DR
-----------------------------------------------------
City | MOREHEAD CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28557-9630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-538-5274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------