Basic Information
Provider Information
NPI: 1003297078
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RECORD
FirstName: GENEVA
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential: NP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4700 BATTLEFIELD PARKWAY
Address2: SUITE 200
City: RINGGOLD
State: GA
PostalCode: 30736
CountryCode: US
TelephoneNumber: 7068614990
FaxNumber: 7068619405
Practice Location
Address1: 4700 BATTLEFIELD PARKWAY
Address2: SUITE 200
City: RINGGOLD
State: GA
PostalCode: 30736
CountryCode: US
TelephoneNumber: 7068614990
FaxNumber: 7068619405
Other Information
ProviderEnumerationDate: 06/15/2015
LastUpdateDate: 07/20/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LA2200XRN234548GAN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
363LA2200X234548GAN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
363LW0102XRN234548GAN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
363LW0102X234548GAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health

No ID Information.


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