Provider Demographics
NPI:1033790993
Name:KPANNAH, PAULINE
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
Last Name:KPANNAH
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 1:4952 GREEN BARK CIR E
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1568
Mailing Address - Country:US
Mailing Address - Phone:678-396-0843
Mailing Address - Fax:
Practice Address - Street 1:4952 GREEN BARK CIR E
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-1568
Practice Address - Country:US
Practice Address - Phone:678-396-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN270758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily