Provider Demographics
NPI:1922639095
Name:MERRITT, LAURA LYNETTE (AA / BA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNETTE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:AA / BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6165 HYDE PARK LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7976
Mailing Address - Country:US
Mailing Address - Phone:678-927-7453
Mailing Address - Fax:
Practice Address - Street 1:6165 HYDE PARK LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7976
Practice Address - Country:US
Practice Address - Phone:678-927-7453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1236592374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA83-1007523Medicaid
GA831007523Medicaid