Provider Demographics
NPI:1417509829
Name:PATEL, POONAMBHEN (NP)
Entity Type:Individual
Prefix:
First Name:POONAMBHEN
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CENTENNIAL TRCE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6409
Mailing Address - Country:US
Mailing Address - Phone:832-549-7273
Mailing Address - Fax:
Practice Address - Street 1:767 PEACHTREE PKWY STE 4
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9348
Practice Address - Country:US
Practice Address - Phone:678-208-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN278255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily