Provider Demographics
NPI:1700633930
Name:RAINEY, HIAWATHA VENESSA
Entity type:Individual
Prefix:
First Name:HIAWATHA
Middle Name:VENESSA
Last Name:RAINEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 KENSINGTON DR S
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-6002
Mailing Address - Country:US
Mailing Address - Phone:706-306-0091
Mailing Address - Fax:
Practice Address - Street 1:3424 KENSINGTON DR S
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-6002
Practice Address - Country:US
Practice Address - Phone:706-306-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000012334376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide