=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902597222
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARRIE SESTAK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2023
-----------------------------------------------------
Last Update Date | 08/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 JOHNSON FY RD NE STE 130
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-953-4034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 WALLACE ST
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68873-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-750-3931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT003526
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------