Provider Demographics
NPI:1467065441
Name:BENN, AJA NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:AJA
Middle Name:NICOLE
Last Name:BENN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 EASTWOOD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7752
Mailing Address - Country:US
Mailing Address - Phone:470-219-0642
Mailing Address - Fax:
Practice Address - Street 1:1968 HAWKS LN NE STE 200
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2283
Practice Address - Country:US
Practice Address - Phone:404-778-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0016132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer