Basic Information
| Provider Information | |||||||||
| NPI: | 1508457631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDDER | ||||||||
| FirstName: | CLAUDETTE | ||||||||
| MiddleName: | ANNMARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2738 LAKE CAPRI DR | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300122945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474825528 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2021 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | GA085276 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.