Healthcare Provider Details

I. General information

NPI: 1396337259
Provider Name (Legal Business Name): STELLA O AYETAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2912 HEART PINE WAY
BUFORD GA
30519-7639
US

IV. Provider business mailing address

2912 HEART PINE WAY
BUFORD GA
30519-7639
US

V. Phone/Fax

Practice location:
  • Phone: 404-247-7377
  • Fax:
Mailing address:
  • Phone: 404-247-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN271306
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: