Provider Demographics
NPI:1962136663
Name:BABA, KONATSU
Entity type:Individual
Prefix:
First Name:KONATSU
Middle Name:
Last Name:BABA
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 1:339 NACOOCHEE DR
Mailing Address - Street 2:
Mailing Address - City:RABUN GAP
Mailing Address - State:GA
Mailing Address - Zip Code:30568-2200
Mailing Address - Country:US
Mailing Address - Phone:209-519-7049
Mailing Address - Fax:
Practice Address - Street 1:339 NACOOCHEE DR
Practice Address - Street 2:
Practice Address - City:RABUN GAP
Practice Address - State:GA
Practice Address - Zip Code:30568-2200
Practice Address - Country:US
Practice Address - Phone:209-519-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAAT0045472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program