=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366056764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCY GREER SORTO NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3437 BIG LEAF CT
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-4633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-936-0899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3437 BIG LEAF CT
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-4633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-936-0899
-----------------------------------------------------
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 | 225994
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------