Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | RN268308 | GA |
NPI | 1003568775 |
---|---|
Provider Name | Kristin Clements |
First Address | Grovetown, GA 30813-0019 |
Second Address | Grovetown, GA 30813-3808 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2022 |
Last Update Date | 24/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RN268308 | NP LICENSE NUMBER (01) | GA |