Provider Demographics
NPI:1548337694
Name:PROFESSIONAL NURSING SERVICES OF NA, LTD
Entity type:Organization
Organization Name:PROFESSIONAL NURSING SERVICES OF NA, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:E
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:LAVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-628-5790
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0067
Mailing Address - Country:US
Mailing Address - Phone:478-628-5790
Mailing Address - Fax:478-628-2954
Practice Address - Street 1:107 JACKSON ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-3908
Practice Address - Country:US
Practice Address - Phone:478-628-5790
Practice Address - Fax:478-628-2954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA158 R 0001163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty