Basic Information
| Provider Information | |||||||||
| NPI: | 1972088052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRAVEEN | ||||||||
| FirstName: | USHA | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | ATTN: TOBIE SHELLEY | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043650966 | ||||||||
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| Practice Location | |||||||||
| Address1: | 663 LANIER PARK DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305012059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784500202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2018 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN200107 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 583530005 | 01 | GA | AANP | OTHER |