Provider Demographics
NPI:1962072017
Name:MABO, DONICIA RAILEY (FNP)
Entity type:Individual
Prefix:
First Name:DONICIA
Middle Name:RAILEY
Last Name:MABO
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 1:1114 GA HIGHWAY 96 STE D3-D5
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2111
Mailing Address - Country:US
Mailing Address - Phone:478-910-1090
Mailing Address - Fax:478-910-1091
Practice Address - Street 1:1114 GA HIGHWAY 96 STE D3-D5
Practice Address - Street 2:
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047-2111
Practice Address - Country:US
Practice Address - Phone:478-910-1090
Practice Address - Fax:478-910-1091
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily