Provider Demographics
NPI:1639278195
Name:DAMICO THOMAS, ELIZABETH A (CNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DAMICO THOMAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 PEACHTREE DUNWOODY RD STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6773
Mailing Address - Country:US
Mailing Address - Phone:404-876-1906
Mailing Address - Fax:
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 400
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068
Practice Address - Country:US
Practice Address - Phone:678-718-2940
Practice Address - Fax:678-718-2941
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093201363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q36885Medicare UPIN
50BBJCWMedicare ID - Type Unspecified