Provider Demographics
NPI:1376531723
Name:ANOM, AILEEN M (NP)
Entity type:Individual
Prefix:MS
First Name:AILEEN
Middle Name:M
Last Name:ANOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:M
Other - Last Name:WIDEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:200 CRESCENT CENTER PARKWAY
Practice Address - Street 2:KAISER PERMANENTE CRESCENT MEDICAL CENTER
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-496-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily