Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | RN058026 | GA |
NPI | 1023137601 |
---|---|
Provider Name | Mrs. Mary Watson Allen |
First Address | Alpharetta, GA 30022-8007 |
Second Address | Atlanta, GA 30322-1013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2007 |
Last Update Date | 16/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00817044A | (05) | GA |