Basic Information
Provider Information | |||||||||
NPI: | 1023081031 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTMAS | ||||||||
FirstName: | MARCY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5007 | ||||||||
Address2: |   | ||||||||
City: | CORDELE | ||||||||
State: | GA | ||||||||
PostalCode: | 31010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292719330 | ||||||||
FaxNumber: | 2292719245 | ||||||||
Practice Location | |||||||||
Address1: | 1329 N 5TH STREET EXT | ||||||||
Address2: |   | ||||||||
City: | CORDELE | ||||||||
State: | GA | ||||||||
PostalCode: | 310153753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292739050 | ||||||||
FaxNumber: | 2292763641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 01/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 119135 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 000969383I | 05 | GA |   | MEDICAID |