Provider Demographics
NPI:1801396007
Name:ARMSTRONG-IDLETTE, SANTRESSA
Entity Type:Individual
Prefix:
First Name:SANTRESSA
Middle Name:
Last Name:ARMSTRONG-IDLETTE
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 1:50 HERITAGE KEEP
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-9149
Mailing Address - Country:US
Mailing Address - Phone:404-556-7714
Mailing Address - Fax:
Practice Address - Street 1:1372 RIVERVIEW RUN LN
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3887
Practice Address - Country:US
Practice Address - Phone:706-207-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003199065AMedicaid