Provider Demographics
NPI:1689336919
Name:REDD, RAEEMAH A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:RAEEMAH
Middle Name:A
Last Name:REDD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:J
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:408 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-2202
Mailing Address - Country:US
Mailing Address - Phone:973-441-6350
Mailing Address - Fax:
Practice Address - Street 1:617 GRIFFIN ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-6707
Practice Address - Country:US
Practice Address - Phone:197-344-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1083237689261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service