Individual
MYIA CANIDATE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
1001 VININGS TRL SE # 1001, SMYRNA, GA 30080-8638
(678) 933-9367
Mailing address
650 PONCE DE LEON AVE NE STE 300, ATLANTA, GA 30308-1864
(678) 933-9367
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
098133
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
098133
—
GA
Enumeration date
02/16/2023
Last updated
02/16/2023
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