Provider Demographics
NPI:1386125516
Name:RAYBOURNE, NEDEGE
Entity type:Individual
Prefix:
First Name:NEDEGE
Middle Name:
Last Name:RAYBOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NEDEGE
Other - Middle Name:
Other - Last Name:RICHAARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:30 CRANBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-9065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 CRANBROOK WAY
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-9065
Practice Address - Country:US
Practice Address - Phone:470-774-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186313363LF0000X
GAF04180532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily