Provider Demographics
NPI:1316578578
Name:MAIAVA, BENTLEY ELIZABETH KNOX (PNP)
Entity Type:Individual
Prefix:
First Name:BENTLEY
Middle Name:ELIZABETH KNOX
Last Name:MAIAVA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 HOLLY SPRINGS PKWY APT 3102
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7472
Mailing Address - Country:US
Mailing Address - Phone:770-990-7382
Mailing Address - Fax:
Practice Address - Street 1:1049 N HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1505
Practice Address - Country:US
Practice Address - Phone:478-922-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249087363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics