Individual
VIRGINIA LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
812 THORNTON PL, DALTON, GA 30720-5228
(404) 578-7393
Mailing address
812 THORNTON PL, DALTON, GA 30720-5228
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
225227
GA
363L00000X
Nurse Practitioner
Primary
225227
GA
Other
Enumeration date
03/23/2022
Last updated
03/23/2022
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