Healthcare Provider Details

I. General information

NPI: 1558960245
Provider Name (Legal Business Name): AVELIN M DIYOMBI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 VILLAGE PL
NEWNAN GA
30265-5708
US

IV. Provider business mailing address

113 VILLAGE PL
NEWNAN GA
30265-5708
US

V. Phone/Fax

Practice location:
  • Phone: 678-378-7596
  • Fax:
Mailing address:
  • Phone: 678-378-7596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0030061735
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number061126829
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: