=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841079811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE WASHINGTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2023
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1435 N EXPRESSWAY STE 301
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-358-5252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1435 N EXPRESSWAY STE 301
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LPN084093
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------