Healthcare Provider Details

I. General information

NPI: 1487865283
Provider Name (Legal Business Name): JUANITA MCKINNON LITTLE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVE
FORT MCPHERSON GA
30330
US

IV. Provider business mailing address

561 WOODS DR NW
ATLANTA GA
30318-6105
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-0242
  • Fax: 404-464-0249
Mailing address:
  • Phone: 404-794-7872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN030849
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: