Provider Demographics
NPI:1114969250
Name:REDDING, EVELYN O'LEARY (FNP-C)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:O'LEARY
Last Name:REDDING
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 OLD JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-3095
Mailing Address - Country:US
Mailing Address - Phone:678-490-0080
Mailing Address - Fax:678-490-0091
Practice Address - Street 1:65 OLD JACKSON ROAD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252
Practice Address - Country:US
Practice Address - Phone:678-490-0080
Practice Address - Fax:678-490-0091
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN054604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000802832EMedicaid
GA000802832EMedicaid
GA50BBKBWMedicare ID - Type UnspecifiedMEDICARE PART B PROVIDER