Provider Demographics
NPI:1811526031
Name:BAKER, MALISSA ABENA
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:ABENA
Last Name:BAKER
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 1:4982 VILLAGER LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3698
Mailing Address - Country:US
Mailing Address - Phone:404-259-1896
Mailing Address - Fax:
Practice Address - Street 1:4982 VILLAGER LN
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3698
Practice Address - Country:US
Practice Address - Phone:404-259-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider