Provider Demographics
NPI:1821502790
Name:BOHANNON, CATHY L
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:L
Last Name:BOHANNON
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 1:1999 BENT CREEK WAY SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-3826
Mailing Address - Country:US
Mailing Address - Phone:404-509-0128
Mailing Address - Fax:
Practice Address - Street 1:1999 BENT CREEK WAY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-3826
Practice Address - Country:US
Practice Address - Phone:404-509-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA823544238OtherIRS