Healthcare Provider Details

I. General information

NPI: 1881211233
Provider Name (Legal Business Name): ADELAIDA LARDUET MAYETA-PEART APRN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE STE 230
CONYERS GA
30012-3819
US

IV. Provider business mailing address

4303 JODECO RD
MCDONOUGH GA
30253-8297
US

V. Phone/Fax

Practice location:
  • Phone: 678-609-4912
  • Fax:
Mailing address:
  • Phone: 770-898-7840
  • Fax: 770-898-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN242101
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN242101
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: