Provider Demographics
NPI:1184028185
Name:NORMAN, RENA
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:NORMAN
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 1:6018 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-3251
Mailing Address - Country:US
Mailing Address - Phone:404-241-2323
Mailing Address - Fax:
Practice Address - Street 1:6018 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-3251
Practice Address - Country:US
Practice Address - Phone:404-241-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA453589171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA453589OtherGA INSURANCE LICENSE