Provider Demographics
NPI:1477190189
Name:FORD, MARIA MONTRICE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:MONTRICE
Last Name:FORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BLUE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2972
Mailing Address - Country:US
Mailing Address - Phone:404-729-7580
Mailing Address - Fax:
Practice Address - Street 1:210 BLUE RIDGE CT
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2972
Practice Address - Country:US
Practice Address - Phone:404-729-7580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF135746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF135746OtherFNP