Provider Demographics
NPI:1548616667
Name:VANTRESS, NIAMBI
Entity Type:Individual
Prefix:
First Name:NIAMBI
Middle Name:
Last Name:VANTRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIAMBI
Other - Middle Name:
Other - Last Name:VANTRESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP, CNS, LCSW
Mailing Address - Street 1:5418 LEE CIR
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2731
Mailing Address - Country:US
Mailing Address - Phone:404-216-5223
Mailing Address - Fax:
Practice Address - Street 1:5418 LEE CIR
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2731
Practice Address - Country:US
Practice Address - Phone:404-216-5223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0029331041C0700X
GARN184231363L00000X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist