Provider Demographics
NPI:1871585158
Name:MCINNIS, NANCY C (PA)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:C
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4291ROYAL MUSTANG WAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058
Mailing Address - Country:US
Mailing Address - Phone:770-985-8512
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHLAKE PKWY
Practice Address - Street 2:STE 280
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4022
Practice Address - Country:US
Practice Address - Phone:770-938-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBCNR03Medicare ID - Type Unspecified