=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811143589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW HORIZONS FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2008
-----------------------------------------------------
Last Update Date | 12/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3725 ZOAR RD
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-6134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-248-1637
-----------------------------------------------------
Fax | 770-248-1638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3725 ZOAR RD
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-6134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-248-1637
-----------------------------------------------------
Fax | 770-248-1638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MS. ANGELLA SAMUELS
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 770-248-1637
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 133706NP
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------