Provider Demographics
NPI:1356088777
Name:TRIMBLE, NATASSIA N
Entity Type:Individual
Prefix:MS
First Name:NATASSIA
Middle Name:N
Last Name:TRIMBLE
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 1:4197 PARKER TRL
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-3261
Mailing Address - Country:US
Mailing Address - Phone:229-474-8838
Mailing Address - Fax:
Practice Address - Street 1:4197 PARKER TRL
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-3261
Practice Address - Country:US
Practice Address - Phone:229-474-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA342000000X
GA051010659342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA87-3935387OtherIRS
GA87-3935387OtherGA SECRETARY OF STATE
GA87-3935387Medicaid