Provider Demographics
NPI:1992211189
Name:SOUTHERLAND, TRINA FELICIA (RN)
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:FELICIA
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 FOX DEN DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4374
Mailing Address - Country:US
Mailing Address - Phone:678-866-5111
Mailing Address - Fax:404-393-9065
Practice Address - Street 1:4240 FOX DEN DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-4374
Practice Address - Country:US
Practice Address - Phone:678-866-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN231662163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty