Basic Information
Provider Information | |||||||||
NPI: | 1154533875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRBY | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2041 MESA VALLEY WAY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 301066828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709441100 | ||||||||
FaxNumber: | 7709446469 | ||||||||
Practice Location | |||||||||
Address1: | 2041 MESA VALLEY WAY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 301066828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709441100 | ||||||||
FaxNumber: | 7709446469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 02/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F0207056 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | RN157966 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 475644168A | 05 | GA |   | MEDICAID | 475644168B | 05 | GA |   | MEDICAID | 475644168C | 05 | GA |   | MEDICAID |