Basic Information
| Provider Information | |||||||||
| NPI: | 1114068889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VADEN | ||||||||
| FirstName: | THEA | ||||||||
| MiddleName: | ANGELA | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 PACES FERRY ROAD | ||||||||
| Address2: | SUITE 1-11000 (ATTENTION DENISE) | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702713421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVENUE | ||||||||
| Address2: | ATHENS REGIONAL MIDWIFERY CLINIC | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064755700 | ||||||||
| FaxNumber: | 7064755718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | RN044251 | GA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | RN044251 | 01 | GA | GA NURSING LICENSE | OTHER |