Provider Demographics
NPI:1336497981
Name:PROFESSIONAL NURSING AND SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL NURSING AND SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHANDA
Authorized Official - Middle Name:LEATRICE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:229-375-4635
Mailing Address - Street 1:7626 ENOCH LAKE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636
Mailing Address - Country:US
Mailing Address - Phone:229-375-4635
Mailing Address - Fax:
Practice Address - Street 1:7626 ENOCH LAKE CIR
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636-3906
Practice Address - Country:US
Practice Address - Phone:229-375-4635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA092-R-0897251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health