Healthcare Provider Details

I. General information

NPI: 1821592478
Provider Name (Legal Business Name): MS. GLADYS KYRIMA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KYRIMA ANDERSON

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1392 PRESERVE PARK DR
LOGANVILLE GA
30052-5828
US

IV. Provider business mailing address

910 ATHENS HWY STE K312
LOGANVILLE GA
30052-4952
US

V. Phone/Fax

Practice location:
  • Phone: 404-992-7747
  • Fax:
Mailing address:
  • Phone: 678-697-1567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 9
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: