MEDICARE: MICHELLE COUSINS MOTT MSN, FNP-C

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	RN150892	GA

General Provider Information

NPI Number	:	1528081882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE COUSINS MOTT MSN, FNP-C

Provider Business Mailing Address
First Line	:	614 VISTA TER
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-6056
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 CLIFTON RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-4201
Country	:	US
Telephone Number	:	404-727-9678
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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