MEDICARE: OCTAVIA SYMONE MARSHALL NP-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	GAANP001688	GA
2	363LF0000X	Family Nurse Practitioner	1140168	TX
3	363LF0000X	Family Nurse Practitioner	906173	MS
4	363LF0000X	Family Nurse Practitioner	95027199	CA

General Provider Information

NPI Number	:	1710750195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCTAVIA SYMONE MARSHALL NP-C

Provider Business Mailing Address
First Line	:	9491 WHALEYS LAKE LN
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-4840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 GLENLAKE PKWY STE 420
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-3489
Country	:	US
Telephone Number	:	404-445-5304
Fax Number	:

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

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	10/30/2025

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