Provider Demographics
NPI:1437442803
Name:BOULAI, DIANE (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BOULAI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 CLIFFHAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6358
Mailing Address - Country:US
Mailing Address - Phone:678-477-3476
Mailing Address - Fax:770-683-6946
Practice Address - Street 1:6944 HIGHWAY 85 STE F
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2960
Practice Address - Country:US
Practice Address - Phone:770-683-6946
Practice Address - Fax:770-683-6949
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
GALPN061853164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)