1255784617 NPI number — DR. JAMIE LYALL THREATT DNP, AGACNP-BC

Table of content: DR. JAMIE LYALL THREATT DNP, AGACNP-BC (NPI 1255784617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255784617 NPI number — DR. JAMIE LYALL THREATT DNP, AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THREATT
Provider First Name:
JAMIE
Provider Middle Name:
LYALL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP, AGACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LYALL
Provider Other First Name:
JAMIE
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255784617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 JOHNSON FERRY ROAD NE
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-257-0006
Provider Business Mailing Address Fax Number:
404-851-1316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 JOHNSON FERRY ROAD NE
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-257-0006
Provider Business Practice Location Address Fax Number:
404-851-1316
Provider Enumeration Date:
07/20/2016

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: 363LA2100X , with the licence number:  RN213384 , 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)





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