Provider Demographics
NPI:1174164289
Name:HEDGE, OCTAVIA MOORE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:MOORE
Last Name:HEDGE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:OCTAVIA
Other - Middle Name:
Other - Last Name:MOORE-HEDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8601 BALDWIN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5626
Mailing Address - Country:US
Mailing Address - Phone:678-948-8753
Mailing Address - Fax:
Practice Address - Street 1:1707 BLAIR BRIDGE RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-5537
Practice Address - Country:US
Practice Address - Phone:678-945-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN-147913-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care