=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336692599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRACTICE ASSOCIATES OF TIFTAREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2016
-----------------------------------------------------
Last Update Date | 07/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 LOVE AVE
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-391-3300
-----------------------------------------------------
Fax | 229-388-1948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 LOVE AVE
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-391-3300
-----------------------------------------------------
Fax | 229-388-1948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. CHRISTY BLANCHETT
-----------------------------------------------------
Credential | BBA-HM
-----------------------------------------------------
Telephone | 229-391-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN089222
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------