Provider Demographics
NPI:1871842427
Name:VAFAEIAN, SAFIAH
Entity Type:Individual
Prefix:
First Name:SAFIAH
Middle Name:
Last Name:VAFAEIAN
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 1:300 WILMOT RD # 3113
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4614
Mailing Address - Country:US
Mailing Address - Phone:855-925-4733
Mailing Address - Fax:
Practice Address - Street 1:950 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1601
Practice Address - Country:US
Practice Address - Phone:855-925-4733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA093127745Medicaid
GA2021507304Medicare NSC