Provider Demographics
NPI:1619054459
Name:CODY, REGINA G (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:G
Last Name:CODY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LESTER RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2119
Mailing Address - Country:US
Mailing Address - Phone:912-662-6501
Mailing Address - Fax:912-681-1012
Practice Address - Street 1:19 LESTER RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2119
Practice Address - Country:US
Practice Address - Phone:912-662-6501
Practice Address - Fax:912-681-1012
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117919163W00000X
GA0364455363LF0000X
GA2009008422363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA976152836DMedicaid
GAP43397Medicare UPIN
GA50BBKDGMedicare PIN