Healthcare Provider Details

I. General information

NPI: 1205715752
Provider Name (Legal Business Name): CORANESHA PRYOR NURSE ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 THE EXCHANGE SE STE 220 PMB 414617
ATLANTA GA
30339
US

IV. Provider business mailing address

1870 THE EXCHANGE SE STE 220 PMB 414617
ATLANTA GA
30339
US

V. Phone/Fax

Practice location:
  • Phone: 912-401-2810
  • Fax:
Mailing address:
  • Phone: 912-401-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0014205562
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: