MEDICARE: FARAH OCTAVIEN AGNP

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	364SG0600X	Gerontology Clinical Nurse Specialist	AG03190021	GA

General Provider Information

NPI Number	:	1629629613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARAH OCTAVIEN AGNP

Provider Business Mailing Address
First Line	:	2873 VILLAGE PARK DR E
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-5712
Country	:	US
Telephone Number	:	678-571-0918
Fax Number	:

Provider Business Practice Location Address
First Line	:	2873 VILLAGE PARK DR E
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-5712
Country	:	US
Telephone Number	:	678-571-0918
Fax Number	:

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

Provider Enumeration Date	:	09/22/2019
Last Update Date	:	09/22/2019

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