Provider Demographics
NPI:1538702170
Name:KING, MAYA TIFFANY JACQUELINE (CPNP)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:TIFFANY JACQUELINE
Last Name:KING
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S SHORE TER
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7399
Mailing Address - Country:US
Mailing Address - Phone:770-349-9698
Mailing Address - Fax:
Practice Address - Street 1:105 S SHORE TER
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7399
Practice Address - Country:US
Practice Address - Phone:770-349-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA290689363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics