Basic Information
| Provider Information | |||||||||
| NPI: | 1306074406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | IMELDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4166 BUFORD HWY NE | ||||||||
| Address2: | SUITE 1102 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303451081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4166 BUFORD HWY NE | ||||||||
| Address2: | SUITE 1102 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303451081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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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 | 363LP0200X | RN192592 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LF0000X | RN192592 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.