Provider Demographics
NPI:1730828294
Name:HARRIS, ANTONIA MAISHA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:MAISHA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 HALBROOKE PL SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-3527
Mailing Address - Country:US
Mailing Address - Phone:706-761-6553
Mailing Address - Fax:
Practice Address - Street 1:939 BOB ARNOLD BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-3258
Practice Address - Country:US
Practice Address - Phone:404-474-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN276975363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty