Provider Demographics
NPI:1972987683
Name:NIMENE, ETOHN
Entity Type:Individual
Prefix:
First Name:ETOHN
Middle Name:
Last Name:NIMENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 MEADOW CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3678
Mailing Address - Country:US
Mailing Address - Phone:678-478-5842
Mailing Address - Fax:
Practice Address - Street 1:3034 MEADOW CHURCH RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3678
Practice Address - Country:US
Practice Address - Phone:678-478-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1946723146N00000X
GALPN091164164W00000X
TX323645164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic