Basic Information
| Provider Information | |||||||||
| NPI: | 1912595943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REID | ||||||||
| FirstName: | TIASHYANA | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2890 VALLEY RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300325765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032909462 | ||||||||
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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: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN097219 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.