Provider Demographics
NPI:1275225179
Name:CANTY, SIEDAH ELIZABETH MONCHAI
Entity Type:Individual
Prefix:
First Name:SIEDAH
Middle Name:ELIZABETH MONCHAI
Last Name:CANTY
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 1:109 CARRIE MAE LN
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3720
Mailing Address - Country:US
Mailing Address - Phone:678-755-3130
Mailing Address - Fax:
Practice Address - Street 1:109 CARRIE MAE LN
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3720
Practice Address - Country:US
Practice Address - Phone:678-755-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1077-40223747P1801X
374J00000X
TN00215404376K00000X
GA172V00000X
GACN0030004934376K00000X
OK320676761022376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker