Provider Demographics
NPI:1205584380
Name:IYER, SRIVIDYA GANESH (NP)
Entity type:Individual
Prefix:
First Name:SRIVIDYA
Middle Name:GANESH
Last Name:IYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:SRIVIDYA
Other - Middle Name:GANESH
Other - Last Name:IYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:4430 SAINT ANDREWS CREST DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9364
Mailing Address - Country:US
Mailing Address - Phone:864-363-1046
Mailing Address - Fax:
Practice Address - Street 1:73 PRESTIGE LN STE 103
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6370
Practice Address - Country:US
Practice Address - Phone:706-265-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240200363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care