MEDICARE: NISSY S CLEETUS

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	163W00000X	Registered Nurse	RN188479	GA

General Provider Information

NPI Number	:	1710844493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NISSY S CLEETUS

Provider Business Mailing Address
First Line	:	382 YELLOW SHOALS CT
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-5136
Country	:	US
Telephone Number	:	770-597-4808
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 PARKLAKE DR NE STE 228
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-3070
Country	:	US
Telephone Number	:	404-935-5900
Fax Number	:	678-252-2172

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

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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Directions to “ NISSY S CLEETUS ” Practice Location

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