Basic Information
Provider Information | |||||||||
NPI: | 1316390339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIFFIN | ||||||||
FirstName: | CHRISTIE | ||||||||
MiddleName: | LONG | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, AGNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORE | ||||||||
OtherFirstName: | CHRISTIE | ||||||||
OtherMiddleName: | LONG | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AGNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 907 18TH ST E STE 400 | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293533422 | ||||||||
FaxNumber: | 2293536060 | ||||||||
Practice Location | |||||||||
Address1: | 1602 MADISON AVE | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293914426 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2016 | ||||||||
LastUpdateDate: | 03/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN172091 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.