Provider Demographics
NPI:1942736160
Name:PRESTIGE ADVANCED HEALTHCARE
Entity Type:Organization
Organization Name:PRESTIGE ADVANCED HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CIERRA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-295-9981
Mailing Address - Street 1:43 BRISBANE CT
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-2370
Mailing Address - Country:US
Mailing Address - Phone:470-295-9981
Mailing Address - Fax:844-740-1379
Practice Address - Street 1:102 MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3225
Practice Address - Country:US
Practice Address - Phone:706-756-5317
Practice Address - Fax:844-740-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-08
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA233631261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1730557752OtherNURSE PRACTITIONER