1962500645 NPI number — DEBORAH LYNN MCBRIDE FNP

Table of content: DEBORAH LYNN MCBRIDE FNP (NPI 1962500645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962500645 NPI number — DEBORAH LYNN MCBRIDE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCBRIDE
Provider First Name:
DEBORAH
Provider Middle Name:
LYNN
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:
WALDEN-MCBRIDE
Provider Other First Name:
DEBORAH
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1962500645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 E 2ND AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-509-3278
Provider Business Mailing Address Fax Number:
706-509-4608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 SHORTER AVE NW
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30165-4290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-509-3300
Provider Business Practice Location Address Fax Number:
706-509-4608
Provider Enumeration Date:
09/20/2006

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: 363L00000X , with the licence number:  073413 , 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: PENDING , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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