Basic Information
Provider Information | |||||||||
NPI: | 1265477863 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATLANTA VA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6 FAIRFIELD DR | ||||||||
Address2: |   | ||||||||
City: | ELLENWOOD | ||||||||
State: | GA | ||||||||
PostalCode: | 302942810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6788335759 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1670 CLAIRMONT RD | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300334004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043216111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 11/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOOKER | ||||||||
AuthorizedOfficialFirstName: | YLBA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
AuthorizedOfficialTelephone: | 4043216111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 018134 | PR | Y |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   |
No ID Information.