Provider Demographics
NPI:1083346001
Name:BLOUNT, DEONTA LASHEA (LPN)
Entity Type:Individual
Prefix:
First Name:DEONTA
Middle Name:LASHEA
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 RAYS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3144
Mailing Address - Country:US
Mailing Address - Phone:470-736-9644
Mailing Address - Fax:404-549-3151
Practice Address - Street 1:798 RAYS RD STE 100
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3144
Practice Address - Country:US
Practice Address - Phone:470-736-9644
Practice Address - Fax:404-549-3151
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN072168261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health