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General NPI Number Information
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NPI Number | 1164035564
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Entity Type | Organization
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Legal Business Name | THE LOTUS HAVEN PC
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Dates
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Enumeration Date | 08/25/2020
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Last Update Date | 12/09/2024
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Provider Practice Location Address
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Address Line | 950 DANNON VW SW STE 4101
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City | ATLANTA
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State | GA
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Zip | 30331-2159
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Country | US
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Telephone | 404-944-1174
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Fax |
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Provider Business Mailing Address
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Address Line | 425 DUTCHVIEW DR
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City | ATLANTA
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State | GA
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Zip | 30349-7642
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TYRONJALA GAINEY- GRANT
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Credential | NP
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Telephone | 404-944-1174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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