MEDICARE: KAYLA MERRITT 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	163W00000X	Registered Nurse	RN209446	GA
2	363LF0000X	Family Nurse Practitioner	RN209446	GA

General Provider Information

NPI Number	:	1770986697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA MERRITT FNP-C

Provider Business Mailing Address
First Line	:	1502 W 3RD ST
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1979
Country	:	US
Telephone Number	:	678-774-0430
Fax Number	:	770-775-3410

Provider Business Practice Location Address
First Line	:	1502 W 3RD ST
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1979
Country	:	US
Telephone Number	:	678-774-0430
Fax Number	:	770-775-3410

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

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	11/18/2014

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