MEDICARE: MS. GEERTRUIDA CORNELIA DISSELDORP RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN100092	GA

General Provider Information

NPI Number	:	1114142544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GEERTRUIDA CORNELIA DISSELDORP RN

Provider Business Mailing Address
First Line	:	1337 SHAW DRIVE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-5627
Country	:	US
Telephone Number	:	404-231-9363
Fax Number	:	404-231-9569

Provider Business Practice Location Address
First Line	:	2660 OSBORNE RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-2832
Country	:	US
Telephone Number	:	404-231-9363
Fax Number	:	404-231-9569

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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