1164916581 NPI number — ANNY SOSEBEE NP-C

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164916581 NPI number — ANNY SOSEBEE NP-C

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SOSEBEE

Provider First Name:

ANNY

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

NP-C

Provider Gender Code:

F

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:

1164916581

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/31/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

396 HISTORIC HWY 441 N

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DEMOREST

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30535

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

396 HISTORIC HWY 441 N

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DEMOREST

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30535

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

706-754-4348

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/19/2018

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LP0200X , with the licence number:  RN191042 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363LF0000X , with the licence number: RN191042 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 003206458C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 003206458B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 003206458E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1773729 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 1773739 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 05752404 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 1773728 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 003206458D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 003206458A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1643451 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 1773742 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".