Healthcare Provider Details

I. General information

NPI: 1871163097
Provider Name (Legal Business Name): LYCHANNEL TICOLE HEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 HIGHWAY 20 W
MCDONOUGH GA
30253-7311
US

IV. Provider business mailing address

1631 HIGHWAY 20 W
MCDONOUGH GA
30253-7311
US

V. Phone/Fax

Practice location:
  • Phone: 770-288-2822
  • Fax:
Mailing address:
  • Phone: 770-288-2822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06211529
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1952405052
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: