Provider Demographics
NPI:1598403628
Name:MENCHION, GERALDINE ECCLESTON (FNP, BC)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:ECCLESTON
Last Name:MENCHION
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 COUNTRY CLUB DR BLDG 100D
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7380
Mailing Address - Country:US
Mailing Address - Phone:404-514-6066
Mailing Address - Fax:678-601-1508
Practice Address - Street 1:175 COUNTRY CLUB DR BLDG 100D
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7380
Practice Address - Country:US
Practice Address - Phone:678-819-5497
Practice Address - Fax:678-601-1508
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2023-01-23
Deactivation Date:2022-09-07
Deactivation Code:
Reactivation Date:2022-10-03
Provider Licenses
StateLicense IDTaxonomies
GARN151173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily