=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275016776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINEQUE ARIANE CHHUN NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2018
-----------------------------------------------------
Last Update Date | 01/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2670 COBB PKWY SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-732-1528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 491 HOPKINS ST SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30310-1671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-963-1842
-----------------------------------------------------
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 | 255-839
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------