Provider Demographics
NPI:1154834406
Name:JAMES, LEQUAWN MONTRELL
Entity Type:Individual
Prefix:
First Name:LEQUAWN
Middle Name:MONTRELL
Last Name:JAMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PHIPPS BLVD NE APT 1601
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3345
Mailing Address - Country:US
Mailing Address - Phone:803-394-4993
Mailing Address - Fax:
Practice Address - Street 1:277 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:347-735-1504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA236509163WE0003X, 363LA2200X
CA95137485363LA2200X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency