Provider Demographics
NPI:1194397265
Name:LE, DAT THANH (FNP-C)
Entity Type:Individual
Prefix:
First Name:DAT
Middle Name:THANH
Last Name:LE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 CHRISTIANA XING
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7026
Mailing Address - Country:US
Mailing Address - Phone:478-244-4306
Mailing Address - Fax:
Practice Address - Street 1:2129 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542
Practice Address - Country:US
Practice Address - Phone:678-782-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily