Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LA2200X | Nurse Practitioner - Adult Health | 234548 | GA |
N | 363LA2200X | Nurse Practitioner - Adult Health | RN234548 | GA |
Y | 363LW0102X | Nurse Practitioner - Women's Health | 234548 | GA |
N | 363LW0102X | Nurse Practitioner - Women's Health | RN234548 | GA |
NPI | 1003297078 |
---|---|
Provider Name | Geneva Marie Record |
First Address | Ringgold, GA 30736 |
Second Address | Ringgold, GA 30736 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2015 |
Last Update Date | 20/07/2015 |