Provider Demographics
NPI:1265955652
Name:CHURCHWELL, BECCA (FNP-BC)
Entity type:Individual
Prefix:
First Name:BECCA
Middle Name:
Last Name:CHURCHWELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8060 RIVER CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4351 OLDE PERIMETER WAY
Practice Address - Street 2:#200 STE 110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30346
Practice Address - Country:US
Practice Address - Phone:334-590-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN269847363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN269847OtherSTATE LICENSE