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General NPI Number Information
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NPI Number | 1205584380
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Entity Type | Individual
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Provider Name | SRIVIDYA GANESH IYER NP
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Gender | Female
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Dates
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Enumeration Date | 03/16/2022
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 73 PRESTIGE LN STE 103
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City | DAWSONVILLE
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State | GA
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Zip | 30534-6370
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Country | US
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Telephone | 706-265-8002
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Fax |
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Provider Business Mailing Address
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Address Line | 4430 SAINT ANDREWS CREST DR
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City | CUMMING
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State | GA
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Zip | 30040-9364
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Country | US
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Telephone | 864-363-1046
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | RN240200
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | APRN-NP240200
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License Number State | GA
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