Provider Demographics
NPI:1174765853
Name:REARDON, ELIZABETH JEAN (NP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:REARDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 EAGLE DR STE 200-B
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8274
Mailing Address - Country:US
Mailing Address - Phone:404-255-5956
Mailing Address - Fax:770-575-3504
Practice Address - Street 1:1816 EAGLE DR STE 200-B
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8274
Practice Address - Country:US
Practice Address - Phone:404-255-5956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily