Provider Demographics
NPI:1922702703
Name:STREET, CELINA (NP)
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 BROOKLINE DR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5605
Mailing Address - Country:US
Mailing Address - Phone:770-595-9450
Mailing Address - Fax:
Practice Address - Street 1:1100 NORTHMEADOW PKWY STE 108
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3871
Practice Address - Country:US
Practice Address - Phone:770-664-4430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA215136208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics