1447714258 NPI number — MRS. JEA'N DEQUIA TERSHA WYATT LAPC, NCC

Table of content: MRS. JEA'N DEQUIA TERSHA WYATT LAPC, NCC (NPI 1447714258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447714258 NPI number — MRS. JEA'N DEQUIA TERSHA WYATT LAPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYATT
Provider First Name:
JEA'N DEQUIA
Provider Middle Name:
TERSHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LAPC, NCC
Provider Gender Code:
F

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:
1447714258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6636 SKY LEAF LN
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:
30213-6527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-466-2943
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 HIGHWAY 74 N STE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-901-6634
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2019

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

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





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