Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 176B00000X | Midwife | CNM05484 | GA |
NPI | 1104484443 |
---|---|
Provider Name | Mrs. Elisa R Jenks |
First Address | Augusta, GA 30912-0001 |
Second Address | Augusta, GA 30912-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2019 |
Last Update Date | 20/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CNM05484 | (05) | GA |