Provider Demographics
NPI:1669740783
Name:ABRAHAM, RENNIE JUANILLO (FNP, NP-C)
Entity type:Individual
Prefix:MR
First Name:RENNIE
Middle Name:JUANILLO
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:FNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 COLLIER RD NW
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1709
Mailing Address - Country:US
Mailing Address - Phone:404-352-3300
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW
Practice Address - Street 2:SUITE 290
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1709
Practice Address - Country:US
Practice Address - Phone:404-352-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-03
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003139537AMedicaid
GA202I507509Medicare PIN