Healthcare Provider Details

I. General information

NPI: 1205114568
Provider Name (Legal Business Name): FARZANA AYUBI AFGHAN CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 FLAGLER CT
LAWRENCEVILLE GA
30044-2031
US

IV. Provider business mailing address

630 MOON RD
LAWRENCEVILLE GA
30046-6108
US

V. Phone/Fax

Practice location:
  • Phone: 678-896-2701
  • Fax: 678-442-0953
Mailing address:
  • Phone: 678-896-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number067-R-0540
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number067-R-0540
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: