Provider Demographics
NPI:1982247433
Name:NELSON, LAQUETA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAQUETA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 HERODIAN WAY SE STE 220
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8500
Mailing Address - Country:US
Mailing Address - Phone:770-383-1415
Mailing Address - Fax:
Practice Address - Street 1:3970 DEPUTY BILL CANTRELL MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-513-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN145567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN145567OtherFNP LICENSE