Provider Demographics
NPI:1003406844
Name:EMMONS, ROXANN (RN)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:EMMONS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 QUAIL CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-1938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 QUAIL CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1938
Practice Address - Country:US
Practice Address - Phone:404-200-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274531163WN0300X, 163WD1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal
No163WN0300XNursing Service ProvidersRegistered NurseNephrology