=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629831631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEDEAH GRACE GILBERT AGACNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2024
-----------------------------------------------------
Last Update Date | 03/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 PEACHTREE ST NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-686-4411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 868 SAYBROOK CIR NW
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-2652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-284-2419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 13-145158-052
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | RN327754
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------