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General NPI Number Information
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NPI Number | 1841987294
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Entity Type | Individual
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Provider Name | LASIDRA BRABSON
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Gender | Female
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Dates
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Enumeration Date | 04/18/2023
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Last Update Date | 04/18/2023
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Provider Practice Location Address
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Address Line | 1580 BOGGS RD STE 700
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City | DULUTH
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State | GA
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Zip | 30096-9097
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Country | US
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Telephone | 678-751-5980
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Fax |
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Provider Business Mailing Address
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Address Line | 3435 SPRING PLACE CT
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City | LOGANVILLE
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State | GA
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Zip | 30052-5291
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Country | US
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Telephone | 678-751-5980
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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 | 363LX0106X
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Taxonomy Name | Occupational Health Nurse Practitioner
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License Number | 217398
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License Number State | GA
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