=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952530016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIFTS FROM GRACE OB/GYN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2009
-----------------------------------------------------
Last Update Date | 07/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6325 HOSPITAL PKWY SUITE 210
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-1549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-622-5889
-----------------------------------------------------
Fax | 770-622-5890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6325 HOSPITAL PKWY SUITE 210
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-1549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-622-5889
-----------------------------------------------------
Fax | 770-622-5890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KIRSTIE DONNYELLE PHILLIPS CUNNINGHAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-622-5889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 048766
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------