=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881228039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHIE COMMUNITY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 S MAIN ST
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-0164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-366-9371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 S MAIN ST
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-0164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-366-9371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KNIOLE LEE
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 912-278-0410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------