=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285103747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN KEYTON OLIVER NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2018
-----------------------------------------------------
Last Update Date | 11/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 DONOVAN HARRISON RD
-----------------------------------------------------
City | WRIGHTSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31096-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-864-4205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6003 US HIGHWAY 319 N
-----------------------------------------------------
City | WRIGHTSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31096-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-864-4205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F01180182
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------