Provider Demographics
NPI:1760856645
Name:363L00000X
Entity Type:Organization
Organization Name:363L00000X
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANETHA
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-464-9424
Mailing Address - Street 1:2171 PEACHTREE RD NE
Mailing Address - Street 2:APT 306
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-6300
Mailing Address - Country:US
Mailing Address - Phone:678-464-9424
Mailing Address - Fax:
Practice Address - Street 1:2171 PEACHTREE RD NE
Practice Address - Street 2:APT 306
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-6300
Practice Address - Country:US
Practice Address - Phone:678-464-9424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363L00000X313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility