Healthcare Provider Details

I. General information

NPI: 1689308611
Provider Name (Legal Business Name): KIRA TIFANIE STAPLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 RONALD REAGAN BLVD
CUMMING GA
30041-6092
US

IV. Provider business mailing address

2860 RONALD REAGAN BLVD
CUMMING GA
30041-6092
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-4793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA004896
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: