Provider Demographics
NPI:1417932567
Name:BIVINS, LAURIE EILEEN (RN, MSN, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:EILEEN
Last Name:BIVINS
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:EILEEN
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CPNP
Mailing Address - Street 1:1664 MULKEY RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1114
Mailing Address - Country:US
Mailing Address - Phone:770-941-7709
Mailing Address - Fax:770-941-6441
Practice Address - Street 1:1664 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1114
Practice Address - Country:US
Practice Address - Phone:770-941-7709
Practice Address - Fax:770-941-6441
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA094302163W00000X
GA85069363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000438688CMedicaid