Healthcare Provider Details

I. General information

NPI: 1992856421
Provider Name (Legal Business Name): MARY ANN KYSER R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 LENORA CHURCH RD BLDG. A
SNELLVILLE GA
30078-3688
US

IV. Provider business mailing address

1148 HIRAM DAVIS RD
LAWRENCEVILLE GA
30045-6600
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-9157
  • Fax: 770-979-7767
Mailing address:
  • Phone: 770-963-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN032522
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: