Provider Demographics
NPI:1801189402
Name:VALDOSTA STATE UNIVERSITY STUDENT HEALTH SERVICES
Entity Type:Organization
Organization Name:VALDOSTA STATE UNIVERSITY STUDENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HIATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-333-5886
Mailing Address - Street 1:200 GEORGIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31698
Mailing Address - Country:US
Mailing Address - Phone:229-333-5886
Mailing Address - Fax:229-249-2791
Practice Address - Street 1:200 GEORGIA AVENUE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31698
Practice Address - Country:US
Practice Address - Phone:229-333-5886
Practice Address - Fax:229-249-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA163WC1400X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No163WC1400XNursing Service ProvidersRegistered NurseCollege HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1093816662OtherSHONTA WINBUSH MD TYPE I NPI
GA1730180191OtherWILLIAM GROW MD TYPE I NPI
GA1336465301OtherKRISTEN DUNCAN WHNP BC TYPE I NPI
GA1023158763OtherBARBARA PEARCE RN TYPE I NPI
GA1447492582OtherIVY FRALICK RN TYPE I NPI
GA1720156417OtherELSIE NAPIER RN TYPE I NPI
GA1841504156OtherDORAINE WEBB RN TYPE I NPI
GA1891095840OtherKAREN BOWSER RN TYPE I NPI
GA1003946781OtherDEBBIE REAGAN MSN ARNP BC TYPE I NPI
GA1679772419OtherSTACY REID RN TYPE I NPI
GA1730308883OtherKIMBERLY S SNOW RN FNP TYPE I NPI
GA1841341500OtherTERESA JOHNSON RN TYPE I NPI
GA1699889121OtherEDWIN L HIATT MD TYPE I NPI
GA1831194760OtherLEON MEEKS MD TYPE I NPI