Provider Demographics
NPI:1780151597
Name:PEPRAH, MAVIS O (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:MAVIS
Middle Name:O
Last Name:PEPRAH
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:MAVIS
Other - Middle Name:
Other - Last Name:DWAMENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:770-496-5555
Mailing Address - Fax:770-939-2887
Practice Address - Street 1:2712 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2512
Practice Address - Country:US
Practice Address - Phone:770-496-5555
Practice Address - Fax:770-939-2887
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223668363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003213488AMedicaid
GAG08685AOtherMEDICARE PTAN