=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316757388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY FAYE BREAULT FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 704 BREEDLOVE DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30655-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-772-0076
-----------------------------------------------------
Fax | 770-751-8014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 704 BREEDLOVE DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30655-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-772-0076
-----------------------------------------------------
Fax | 770-751-8014
-----------------------------------------------------
=====================================================
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 | RN311460
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------