Provider Demographics
NPI:1720471147
Name:THEODOR, EUNICE (FNP)
Entity type:Individual
Prefix:
First Name:EUNICE
Middle Name:
Last Name:THEODOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2266
Mailing Address - Country:US
Mailing Address - Phone:770-947-3000
Mailing Address - Fax:770-947-3012
Practice Address - Street 1:8820 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2266
Practice Address - Country:US
Practice Address - Phone:770-947-3000
Practice Address - Fax:770-947-3012
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172755363LP2300X
GARN244960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720471147Medicaid