Provider Demographics
NPI:1619216637
Name:ANDERSON, ATLEMISIA M
Entity Type:Individual
Prefix:
First Name:ATLEMISIA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 PALM ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-4036
Mailing Address - Country:US
Mailing Address - Phone:229-379-1007
Mailing Address - Fax:229-236-0356
Practice Address - Street 1:1304 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4749
Practice Address - Country:US
Practice Address - Phone:229-379-1007
Practice Address - Fax:229-236-0356
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA453186031343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)