Provider Demographics
NPI:1831659317
Name:LYDIA, KARINA TAN
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:TAN
Last Name:LYDIA
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 1:160 CLAIREMONT AVE STE 445
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2574
Mailing Address - Country:US
Mailing Address - Phone:404-712-2000
Mailing Address - Fax:
Practice Address - Street 1:160 CLAIREMONT AVE STE 445
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2574
Practice Address - Country:US
Practice Address - Phone:404-500-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242953163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse