Healthcare Provider Details

I. General information

NPI: 1679043913
Provider Name (Legal Business Name): NORDWANNA VENITE-LUBIN HYSONS LPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7387 MALENTA CT APT C
FORT STEWART GA
31315-1243
US

IV. Provider business mailing address

7387 MALENTA CT APT C
FORT STEWART GA
31315-1243
US

V. Phone/Fax

Practice location:
  • Phone: 941-467-5803
  • Fax:
Mailing address:
  • Phone: 941-467-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN094918
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: