1639583776 NPI number — ANNA LOUISE RICHARDSON FNP

Table of content: ANNA LOUISE RICHARDSON FNP (NPI 1639583776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639583776 NPI number — ANNA LOUISE RICHARDSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
ANNA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1639583776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 TOWNPARK DR NW
Provider Second Line Business Mailing Address:
STE 240
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30144-5802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-485-3723
Provider Business Mailing Address Fax Number:
678-803-6944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3780 OLD NORCROSS RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-855-2244
Provider Business Practice Location Address Fax Number:
404-793-6105
Provider Enumeration Date:
06/17/2014

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN240818 , 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)

  • Identifier: 2014009774 . This is a "ANCC" identifier . This identifiers is of the category "OTHER".




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