MEDICARE: LOTOYA ANTHONY PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	407606	NY
2	171M00000X	Case Manager/Care Coordinator
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN-NP207368	GA

General Provider Information

NPI Number	:	1417712738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOTOYA ANTHONY PMHNP-BC

Provider Business Mailing Address
First Line	:	175 BRADFORD SQ STE D-2
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-1967
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 BRADFORD SQ STE D-2
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-1967
Country	:	US
Telephone Number	:	770-549-3627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2024
Last Update Date	:	02/12/2026

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