=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700394269
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRI LYNN LEDOUX AGACNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2018
-----------------------------------------------------
Last Update Date | 05/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6572 RIVER PARK DR STE 101
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-669-9966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15489
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31416-2189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-819-5999
-----------------------------------------------------
Fax | 912-819-5980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN227849
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------