1972743623 NPI number — KIM SANDY TEAGUE RN, MS, CNS

Table of content: KIM SANDY TEAGUE RN, MS, CNS (NPI 1972743623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972743623 NPI number — KIM SANDY TEAGUE RN, MS, CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEAGUE
Provider First Name:
KIM
Provider Middle Name:
SANDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MS, CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972743623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
985 RIDGE TARN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-616-3454
Provider Business Mailing Address Fax Number:
404-616-4737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
985 RIDGE TARN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30350-3426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-399-9365
Provider Business Practice Location Address Fax Number:
770-399-1871
Provider Enumeration Date:
02/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
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Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SP0808X , with the licence number:  RN105719 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)