Healthcare Provider Details

I. General information

NPI: 1912545393
Provider Name (Legal Business Name): KANISHIA GORDON HAIR REPL SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MEMORIAL DR SE STE 209
ATLANTA GA
30312-2286
US

IV. Provider business mailing address

2025 CLEARSTREAM OVERLOOK
STONE MOUNTAIN GA
30088-4438
US

V. Phone/Fax

Practice location:
  • Phone: 404-836-3845
  • Fax:
Mailing address:
  • Phone: 203-565-5872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: