MEDICARE: PROFESSIONAL NURSING AND SUPPORT SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency	RN210699	GA
2	253Z00000X	In Home Supportive Care Agency	092-R-0897	GA

General Provider Information

NPI Number	:	1134409519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL NURSING AND SUPPORT SERVICES LLC

Provider Business Mailing Address
First Line	:	7626 ENOCH LAKE CIR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-3906
Country	:	US
Telephone Number	:	229-559-4607
Fax Number	:

Provider Business Practice Location Address
First Line	:	7626 ENOCH LAKE CIR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-3906
Country	:	US
Telephone Number	:	229-559-4607
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LASHANDA L WILLIAMS
Credential	:	REGISTERED NURSE
Telephone Number	:	229-559-4607

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	08/17/2011

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