Provider Demographics
NPI:1609482140
Name:DARRELL, ANTRONETTE (LPN)
Entity Type:Individual
Prefix:
First Name:ANTRONETTE
Middle Name:
Last Name:DARRELL
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 1:1578 CHERRY HILL RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6835
Mailing Address - Country:US
Mailing Address - Phone:716-465-1797
Mailing Address - Fax:
Practice Address - Street 1:1578 CHERRY HILL RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6835
Practice Address - Country:US
Practice Address - Phone:716-465-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN084209164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse