1063391274 NPI number — MEDICAL & MENTAL HOLISTIC HEALTHCARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063391274 NPI number — MEDICAL & MENTAL HOLISTIC HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL & MENTAL HOLISTIC HEALTHCARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063391274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7544 SOUTHLAKE PKWY STE 102B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30236-2495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-240-4849
Provider Business Mailing Address Fax Number:
678-737-1743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7544 SOUTHLAKE PKWY STE 102B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30236-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-240-4849
Provider Business Practice Location Address Fax Number:
678-737-1743
Provider Enumeration Date:
09/01/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
NADINE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRIMARY CARE NURSE PRACTITIONER
Authorized Official Telephone Number:
678-599-3670

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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