Provider Demographics
NPI:1669012266
Name:LAND, REGINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:MARIE
Last Name:LAND
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 1:1809 LAUREL GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30344-8215
Mailing Address - Country:US
Mailing Address - Phone:678-702-3291
Mailing Address - Fax:
Practice Address - Street 1:1809 LAUREL GREEN WAY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-8215
Practice Address - Country:US
Practice Address - Phone:678-702-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver