Healthcare Provider Details

I. General information

NPI: 1225717283
Provider Name (Legal Business Name): VIVIEN KUBRICKA EADY CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIVIEN KUBRICKA

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 02/09/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

275 COLLIER RD NW STE 450
ATLANTA GA
30309-1748
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-5000
  • Fax:
Mailing address:
  • Phone: 404-839-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number11943
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: