=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871283705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA MARIE MISSINI CNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2023
-----------------------------------------------------
Last Update Date | 05/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 RUSSETWOOD LN
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-508-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 616 RUSSETWOOD LN
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-508-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 0030084770
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------