Healthcare Provider Details

I. General information

NPI: 1447654132
Provider Name (Legal Business Name): HEATHER BOHANNON-IYAMA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COLLIER RD NW STE 775
ATLANTA GA
30309-1608
US

IV. Provider business mailing address

35 COLLIER RD NW STE 775
ATLANTA GA
30309-1608
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-5959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberGAA-NP002236
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19097
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19097
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberGAA-NP002236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: