Provider Demographics
NPI:1386092997
Name:BOOMS, JILL (RN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BOOMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:DORMAN-POTTHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-389-6789
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:250 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2244
Practice Address - Country:US
Practice Address - Phone:706-389-6789
Practice Address - Fax:706-227-7249
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN082686163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse