Provider Demographics
NPI:1073392130
Name:EASLEY, TAWANNA (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:EASLEY
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 LAJEAN DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4148
Mailing Address - Country:US
Mailing Address - Phone:678-437-6348
Mailing Address - Fax:
Practice Address - Street 1:2900 LAJEAN DR
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4148
Practice Address - Country:US
Practice Address - Phone:678-437-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0935821744P3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management