Healthcare Provider Details

I. General information

NPI: 1639302953
Provider Name (Legal Business Name): MANOUCHKA LOMINY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARIE MANOUCHKA BELLERICE

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 POWDER SPRINGS RD SW STE 510
MARIETTA GA
30064-4849
US

IV. Provider business mailing address

721 LAUREL CHASE SW
MARIETTA GA
30064-3968
US

V. Phone/Fax

Practice location:
  • Phone: 770-875-8889
  • Fax:
Mailing address:
  • Phone: 770-429-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number190413
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number190413
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: