Provider Demographics
NPI:1811763535
Name:SWANS, DYSELL
Entity type:Individual
Prefix:MS
First Name:DYSELL
Middle Name:
Last Name:SWANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 EVANS MILL RD STE 330
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2481
Mailing Address - Country:US
Mailing Address - Phone:678-577-6111
Mailing Address - Fax:
Practice Address - Street 1:2906 EVANS MILL RD STE A
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038-2445
Practice Address - Country:US
Practice Address - Phone:678-577-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAADC000328261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care