Healthcare Provider Details

I. General information

NPI: 1669404067
Provider Name (Legal Business Name): LAILA ISMAIL MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 COOPER LAKES DR
GRAYSON GA
30017-2977
US

IV. Provider business mailing address

1940 COOPER LAKES DR
GRAYSON GA
30017-2977
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-0442
  • Fax:
Mailing address:
  • Phone: 770-339-0442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number2006021642
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: