Healthcare Provider Details

I. General information

NPI: 1346740933
Provider Name (Legal Business Name): LAURETTA NESTER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HARDY RD
BROOKS GA
30205-2314
US

IV. Provider business mailing address

330 HARDY RD
BROOKS GA
30205-2314
US

V. Phone/Fax

Practice location:
  • Phone: 678-588-1478
  • Fax:
Mailing address:
  • Phone: 678-588-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3406
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: