Healthcare Provider Details

I. General information

NPI: 1134974173
Provider Name (Legal Business Name): PERCINA LYNETTE HALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5193 HOWELL CT
MORROW GA
30260-3972
US

IV. Provider business mailing address

5193 HOWELL CT
MORROW GA
30260-3972
US

V. Phone/Fax

Practice location:
  • Phone: 470-651-5060
  • Fax:
Mailing address:
  • Phone: 470-651-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86418971
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: