Provider Demographics
NPI:1700521093
Name:GOFAN-YLEAH, MAGGIE L (NP)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:L
Last Name:GOFAN-YLEAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 LEGACY WALK CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-7833
Mailing Address - Country:US
Mailing Address - Phone:678-637-1247
Mailing Address - Fax:
Practice Address - Street 1:2612 LEGACY WALK CT
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7833
Practice Address - Country:US
Practice Address - Phone:678-637-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF07210811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily