Healthcare Provider Details

I. General information

NPI: 1750592556
Provider Name (Legal Business Name): MARTHA STEWART MCNAIR 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 AVENUE
FORT MCPHERSON GA
30349
US

IV. Provider business mailing address

3075 BAXLEY CT
COLLEGE PARK GA
30349-4704
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-0242
  • Fax: 404-464-0249
Mailing address:
  • Phone: 770-991-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN18604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: