MEDICARE: DR. CORETTA D. GERVIN HEALTHCARE

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	363L00000X	Nurse Practitioner
2	163WH0200X	Home Health Registered Nurse

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467091629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. CORETTA D. GERVIN HEALTHCARE

Provider Business Mailing Address
First Line	:	414 N WESTOVER BLVD STE D1
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-2102
Country	:	US
Telephone Number	:	404-710-6466
Fax Number	:	229-389-2573

Provider Business Practice Location Address
First Line	:	414 N WESTOVER BLVD STE D1
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-2102
Country	:	US
Telephone Number	:	404-710-6646
Fax Number	:	229-234-1391

Authorized Official
Title or Position	:	CEO
Name	:	DR. CORETTA DELIA KEITH
Credential	:	DNP, FNP-BC
Telephone Number	:	404-710-6646

Provider Enumeration Date	:	01/04/2020
Last Update Date	:	08/10/2023

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