Provider Demographics
NPI:1740006022
Name:ETIENNE-KLASS, DANIELA JASMINE
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:JASMINE
Last Name:ETIENNE-KLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELA
Other - Middle Name:JASMINE
Other - Last Name:ETIENNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3715 WOLVERTON CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3719
Mailing Address - Country:US
Mailing Address - Phone:404-825-2648
Mailing Address - Fax:
Practice Address - Street 1:3715 WOLVERTON CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3719
Practice Address - Country:US
Practice Address - Phone:404-825-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN263814363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner