1063108645 NPI number — LA KENYA JA'REE ANDERSON

Table of content: LA KENYA JA'REE ANDERSON (NPI 1063108645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063108645 NPI number — LA KENYA JA'REE ANDERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
LA KENYA
Provider Middle Name:
JA'REE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
LA KENYA
Provider Other Middle Name:
JA'REE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063108645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6945 MERRYWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBURN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30213-3165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-448-6172
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 HAMILTON E HOLMES DR NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30318-7421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-802-3100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)