Provider Demographics
NPI:1629519202
Name:NURSE PRACTIONER
Entity Type:Organization
Organization Name:NURSE PRACTIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-579-1658
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-7234
Mailing Address - Country:US
Mailing Address - Phone:404-579-1658
Mailing Address - Fax:
Practice Address - Street 1:4044 GEORGE BUSBEE PKWY NW APT 4207
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6890
Practice Address - Country:US
Practice Address - Phone:404-579-1658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDENT CONTRACTOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA193760261QC1500X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No305S00000XManaged Care OrganizationsPoint of Service