Provider Demographics
NPI:1720447493
Name:DANIELS, KOLISHA DEE (NP)
Entity Type:Individual
Prefix:
First Name:KOLISHA
Middle Name:DEE
Last Name:DANIELS
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 1:1355 PEACHTREE ST NE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3276
Mailing Address - Country:US
Mailing Address - Phone:678-223-7774
Mailing Address - Fax:678-223-7799
Practice Address - Street 1:1200 LOWER FAYETTEVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1133
Practice Address - Country:US
Practice Address - Phone:678-631-4610
Practice Address - Fax:678-631-4611
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213104363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175704AMedicaid
GA003175704DMedicaid
GA003175704AMedicaid