Healthcare Provider Details

I. General information

NPI: 1720653355
Provider Name (Legal Business Name): LYGHT BULB MOMENTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOWE STREET BUILDING A ; PO BOX 105 SUITE 105
RUTLAND VT
05701-3802
US

IV. Provider business mailing address

12247 BIG CANOE
BIG CANOE GA
30143-5161
US

V. Phone/Fax

Practice location:
  • Phone: 888-987-3991
  • Fax: 888-502-6598
Mailing address:
  • Phone: 888-987-3991
  • Fax: 888-502-6598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TINEY RAY
Title or Position: NP
Credential:
Phone: 678-701-4679