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General NPI Number Information
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NPI Number | 1760856645
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Entity Type | Organization
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Legal Business Name | 363L00000X
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Dates
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Enumeration Date | 11/16/2015
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Last Update Date | 11/16/2015
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Provider Practice Location Address
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Address Line | 2171 PEACHTREE RD NE APT 306
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City | ATLANTA
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State | GA
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Zip | 30309-6300
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Country | US
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Telephone | 678-464-9424
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Fax |
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Provider Business Mailing Address
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Address Line | 2171 PEACHTREE RD NE APT 306
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City | ATLANTA
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State | GA
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Zip | 30309-6300
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Country | US
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Telephone | 678-464-9424
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. ANETHA DEBORAH PETERSON
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Credential |
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Telephone | 678-464-9424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 363L00000X
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License Number State | GA
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