Provider Demographics
NPI:1710603212
Name:MAHDI, AQUILA'
Entity Type:Individual
Prefix:
First Name:AQUILA'
Middle Name:
Last Name:MAHDI
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 1:6354 SHANNON PKWY
Mailing Address - Street 2:SUITE 17D
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291
Mailing Address - Country:US
Mailing Address - Phone:404-884-8564
Mailing Address - Fax:
Practice Address - Street 1:6354 SHANNON PKWY
Practice Address - Street 2:SUITE 17D
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-3029
Practice Address - Country:US
Practice Address - Phone:404-884-8564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20211878171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty