Healthcare Provider Details

I. General information

NPI: 1659607836
Provider Name (Legal Business Name): MS. IRIS MARIA ADAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8198 CHICAGO AVE
DOUGLASVILLE GA
30134-1106
US

IV. Provider business mailing address

8198 CHICAGO AVE
DOUGLASVILLE GA
30134-1106
US

V. Phone/Fax

Practice location:
  • Phone: 678-923-1351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number310893-031
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN085449
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberLPN085449
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberLPN085449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: