Provider Demographics
NPI:1871163097
Name:HEAD, LYCHANNEL TICOLE
Entity type:Individual
Prefix:
First Name:LYCHANNEL
Middle Name:TICOLE
Last Name:HEAD
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 1:4865 BILL GARDNER PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3644
Mailing Address - Country:US
Mailing Address - Phone:770-692-0100
Mailing Address - Fax:
Practice Address - Street 1:4865 BILL GARDNER PKWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3644
Practice Address - Country:US
Practice Address - Phone:770-692-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF06211529363LF0000X
GA1952405052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily