Provider Demographics
NPI:1154186831
Name:LY, SUNTANA (RN)
Entity type:Individual
Prefix:
First Name:SUNTANA
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2966 GWINNSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-4508
Mailing Address - Country:US
Mailing Address - Phone:678-294-0230
Mailing Address - Fax:
Practice Address - Street 1:231 W HANCOCK ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3375
Practice Address - Country:US
Practice Address - Phone:478-455-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254844163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse