Provider Demographics
NPI:1255575890
Name:GEORGIA SOUTHERN UNIVERSITY SCHOOL OF NURSING COMMUNITY NURSING CENTER
Entity type:Organization
Organization Name:GEORGIA SOUTHERN UNIVERSITY SCHOOL OF NURSING COMMUNITY NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING CLINIC
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWNE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:912-478-5166
Mailing Address - Street 1:250 FORREST DR
Mailing Address - Street 2:RM# 1004
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30460-0001
Mailing Address - Country:US
Mailing Address - Phone:912-478-5166
Mailing Address - Fax:912-478-5400
Practice Address - Street 1:250 FORREST DR
Practice Address - Street 2:RM# 1004
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-0001
Practice Address - Country:US
Practice Address - Phone:912-478-5166
Practice Address - Fax:912-478-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117953 NP261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health