Basic Information
| Provider Information | |||||||||
| NPI: | 1578596029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLIBURTON-FOSTER | ||||||||
| FirstName: | NADINE | ||||||||
| MiddleName: | SONJA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALLIBURTON | ||||||||
| OtherFirstName: | NADINE | ||||||||
| OtherMiddleName: | SONJA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2575 PEACHTREE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300417562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708888777 | ||||||||
| FaxNumber: | 7708888779 | ||||||||
| Practice Location | |||||||||
| Address1: | 2575 PEACHTREE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708888777 | ||||||||
| FaxNumber: | 7708888779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27038 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 060079 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 237071919A | 05 | GA | MEDICAID |