Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | RN215790 | GA |
NPI | 1003466483 |
---|---|
Provider Name | Mrs. Brandie Ann Villanova |
First Address | Mcdonough, GA 30253-9000 |
Second Address | Mcdonough, GA 30253-9000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2019 |
Last Update Date | 17/09/2019 |