MEDICARE: LASHAWNA ERVIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT012536	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MT012536	OTHER	GA	MASSAGE THERAPY

General Provider Information

NPI Number	:	1639777352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LASHAWNA ERVIN

Provider Business Mailing Address
First Line	:	1115 MARSH TRAIL CIR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5737
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1804
Country	:	US
Telephone Number	:	678-895-0198
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	10/14/2020

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Directions to “ LASHAWNA ERVIN ” Practice Location

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