Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | RN165131 | GA |
NPI | 1023529914 |
---|---|
Provider Name | Tina L. Hathaway |
First Address | Statesboro, GA 30458-0872 |
Second Address | Statesboro, GA 30458-0872 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2017 |
Last Update Date | 17/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RN165131 | NURSE PRACTITIONER (01) | GA |
RN165131 | NURSING LICENSE (01) | GA |