Healthcare Provider Details

I. General information

NPI: 1518262641
Provider Name (Legal Business Name): HERCHELLE HAYSMAN COHEN A.N.P.-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HERCHELLE HAYSMAN A.N.P.-BC

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4308
US

IV. Provider business mailing address

565 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4308
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-5131
  • Fax: 770-995-3482
Mailing address:
  • Phone: 770-995-5131
  • Fax: 770-995-3482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN204554
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: