MEDICARE: ELITE PRIME HEALTH

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	363LF0000X	Family Nurse Practitioner	13630	TN

General Provider Information

NPI Number	:	1396270294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE PRIME HEALTH

Provider Business Mailing Address
First Line	:	3270 WALTON RIVERWOOD LN SE
Second Line	:	3056
City	:	ATLANTA
State	:	GA
Zip	:	30339-3561
Country	:	US
Telephone Number	:	901-573-7374
Fax Number	:

Provider Business Practice Location Address
First Line	:	3270 WALTON RIVERWOOD LN SE
Second Line	:	3056
City	:	ATLANTA
State	:	GA
Zip	:	30339-3561
Country	:	US
Telephone Number	:	901-573-7374
Fax Number	:

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	MALINDA CONRAD
Credential	:	FNP-BC
Telephone Number	:	901-573-7374

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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Directions to “ELITE PRIME HEALTH ” Practice Location

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