Provider Demographics
NPI:1114290764
Name:PATRICK, JILL MELAINE (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MELAINE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MELANIE
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4295 COUNTRY GARDEN WALK NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2399
Mailing Address - Country:US
Mailing Address - Phone:770-235-2462
Mailing Address - Fax:
Practice Address - Street 1:50 PLAZA WAY NW STE E
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1141
Practice Address - Country:US
Practice Address - Phone:770-732-5101
Practice Address - Fax:770-974-3955
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128940363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003130618AMedicaid