Provider Demographics
NPI:1134570310
Name:IMANI, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:IMANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56147
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30343-0147
Mailing Address - Country:US
Mailing Address - Phone:404-932-9405
Mailing Address - Fax:
Practice Address - Street 1:3805 PRESIDENTIAL PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3720
Practice Address - Country:US
Practice Address - Phone:404-932-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator