Provider Demographics
NPI:1134409519
Name:PROFESSIONAL NURSING AND SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:PROFESSIONAL NURSING AND SUPPORT SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LASHANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:229-559-4607
Mailing Address - Street 1:7626 ENOCH LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3906
Mailing Address - Country:US
Mailing Address - Phone:229-559-4607
Mailing Address - Fax:
Practice Address - Street 1:7626 ENOCH LAKE CIR
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636-3906
Practice Address - Country:US
Practice Address - Phone:229-559-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210699251J00000X
GA092-R-0897253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care