Provider Demographics
NPI:1851905442
Name:FLENTALL, NIJJA (PA)
Entity Type:Individual
Prefix:
First Name:NIJJA
Middle Name:
Last Name:FLENTALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NIJJA
Other - Middle Name:
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1400 RIVER PL
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5600
Practice Address - Country:US
Practice Address - Phone:770-848-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant