MEDICARE: KIRKLEY GRIFFETH JOCK FNP-BC

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	RN218349	GA

General Provider Information

NPI Number	:	1548692221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRKLEY GRIFFETH JOCK FNP-BC

Provider Business Mailing Address
First Line	:	4421 CARNES STREET
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-5305
Country	:	US
Telephone Number	:	478-621-2072
Fax Number	:	678-540-8623

Provider Business Practice Location Address
First Line	:	4421 CARNES STREET
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-5305
Country	:	US
Telephone Number	:	478-621-2072
Fax Number	:	678-540-8623

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

Provider Enumeration Date	:	08/05/2013
Last Update Date	:	12/28/2015

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