Healthcare Provider Details

I. General information

NPI: 1548337694
Provider Name (Legal Business Name): PROFESSIONAL NURSING SERVICES OF NA, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 JACKSON ST
GORDON GA
31031-3908
US

IV. Provider business mailing address

PO BOX 67
GORDON GA
31031-0067
US

V. Phone/Fax

Practice location:
  • Phone: 478-628-5790
  • Fax: 478-628-2954
Mailing address:
  • Phone: 478-628-5790
  • Fax: 478-628-2954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number158 R 0001
License Number StateGA

VIII. Authorized Official

Name: MR. E EDWIN LAVENDER
Title or Position: CEO
Credential:
Phone: 478-628-5790