Provider Demographics
NPI:1669757449
Name:JORDAN, KATRINA TOLLIVER (LPN)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:TOLLIVER
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:NAKIA
Other - Last Name:TOLLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 ANDERSON MILL RD APT 1107
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:770-693-6773
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY ROAD
Practice Address - Street 2:BULDING 400 SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:866-587-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN084084164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse