Provider Demographics
NPI:1720385925
Name:SOUTHSIDE FAMILY PRACTICE
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP-C
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ONUNKA
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:770-629-5410
Mailing Address - Street 1:5898 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:770-629-5410
Mailing Address - Fax:678-519-2580
Practice Address - Street 1:5898 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:770-629-5410
Practice Address - Fax:678-519-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN094938NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty