Provider Demographics
NPI:1447144407
Name:ATLANTA FOOT FAIRY LLC
Entity type:Organization
Organization Name:ATLANTA FOOT FAIRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHANTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISON-KOUROUMA
Authorized Official - Suffix:
Authorized Official - Credentials:BSN-RN
Authorized Official - Phone:678-544-6179
Mailing Address - Street 1:4810 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-3616
Mailing Address - Country:US
Mailing Address - Phone:678-544-6179
Mailing Address - Fax:
Practice Address - Street 1:4810 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3616
Practice Address - Country:US
Practice Address - Phone:678-544-6179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health