=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336457597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUESTROS NINOS OUR KIDS PEDIATRICS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2010
-----------------------------------------------------
Last Update Date | 09/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 CARPENTER DR NE SUITE 201
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-4928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-732-6007
-----------------------------------------------------
Fax | 770-732-8242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 393 MAXHAM RD STE. A&B
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30168-5539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-732-6007
-----------------------------------------------------
Fax | 770-732-8242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/HEAD NURSE PRACTITIONER
-----------------------------------------------------
Name | MARY E. CAHILL-ROBERTS
-----------------------------------------------------
Credential | CPNP
-----------------------------------------------------
Telephone | 770-732-6007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------