=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487989885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMY H MADDOX RN/MSN/FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2009
-----------------------------------------------------
Last Update Date | 03/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 KITE ROAD
-----------------------------------------------------
City | SWAINSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-289-1265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 KITE ROAD P.O. BOX 879
-----------------------------------------------------
City | SWAINSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-289-1265
-----------------------------------------------------
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 | RN166580
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------