Healthcare Provider Details

I. General information

NPI: 1912775263
Provider Name (Legal Business Name): KOSSIWA YAWLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 NORTH AVE STE F
JONESBORO GA
30236-8408
US

IV. Provider business mailing address

118 NORTH AVE STE F
JONESBORO GA
30236-8408
US

V. Phone/Fax

Practice location:
  • Phone: 404-509-6192
  • Fax:
Mailing address:
  • Phone: 404-509-6192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number268783
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN268783
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: