Healthcare Provider Details

I. General information

NPI: 1295342731
Provider Name (Legal Business Name): EVELYN ANITA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CHARLIE FULLER RD
GRANTVILLE GA
30220-2801
US

IV. Provider business mailing address

202 CHARLIE FULLER RD
GRANTVILLE GA
30220-2801
US

V. Phone/Fax

Practice location:
  • Phone: 770-927-2290
  • Fax: 404-522-2935
Mailing address:
  • Phone: 770-927-2290
  • Fax: 404-522-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number113357
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: