Basic Information
Provider Information | |||||||||
NPI: | 1255521647 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPRINGER | ||||||||
FirstName: | KEATRINA | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REYNOLDS | ||||||||
OtherFirstName: | KEATRINA | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CPNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 119 AMBULANCE DR | ||||||||
Address2: | SUITE 202 | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301173857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708388710 | ||||||||
FaxNumber: | 7708388563 | ||||||||
Practice Location | |||||||||
Address1: | 148 CLINIC AVE | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708388640 | ||||||||
FaxNumber: | 7708388650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2007 | ||||||||
LastUpdateDate: | 05/09/2016 | ||||||||
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 | 363LP0200X | RN205796 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | RN205796 | 01 | GA | NP LICENSE | OTHER |