Healthcare Provider Details

I. General information

NPI: 1912605494
Provider Name (Legal Business Name): IVANNA JANESSA CABALLERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 LAWRENCEVILLE SUWANEE RD STE A3
SUWANEE GA
30024-7488
US

IV. Provider business mailing address

1525 GRAYSON HWY APT 1823
GRAYSON GA
30017-1907
US

V. Phone/Fax

Practice location:
  • Phone: 470-589-1878
  • Fax:
Mailing address:
  • Phone: 201-565-4175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: